<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603798
Report Date: 08/07/2025
Date Signed: 08/07/2025 02:06:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2025 and conducted by Evaluator Daniel Konishi
COMPLAINT CONTROL NUMBER: 28-AS-20250731140624
FACILITY NAME:EVELYN'S MANORFACILITY NUMBER:
198603798
ADMINISTRATOR:HALLMAN, KAYLONFACILITY TYPE:
740
ADDRESS:1126 E 82ND STREETTELEPHONE:
(310) 739-9303
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY:6CENSUS: 2DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kaylon Hallman, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring that resident is administered their medications as necessary.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Daniel Konishi conducted an initial 10-day complaint visit in regards to the allegation listed above. LPA explained the purpose of the visit to Kaylon Hallman, the Administrator for the facility that assisted with the visit.

The investigation consisted of the following: LPA obtained copies of Staff Roster, Resident Roster, Weekly Menu, Diabetic Meal Plan. and Resident #1 (R1) files such as: Physician’s Report, Daily Shower Logs (July 2025), Medication Administration Record (July 2025). LPA toured the facility's kitchen. LPA interviewed the Assistant Administrator, Staff #1 (S1) and Former Resident #1 (FR1), Resident # 1 (R1), and Resident #2 (R2).

The investigation revealed the following: in regards to the allegation “Staff are not ensuring that resident is administered their medications as necessary.” It is alleged that staff did not provide FR1 medication for three days to help manage hypertension and diabetes.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20250731140624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EVELYN'S MANOR
FACILITY NUMBER: 198603798
VISIT DATE: 08/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interview, FR1 corroborated with the allegation and stated on not receiving medication for hypertension to manage his blood pressure from the staff for three to four days while living at the facility. Based on resident interview, one (1) out of two (2) residents denied the allegation and stated on receiving medications as prescribed and had no issues. One (1) out of two (2) residents stated being independent and medication management is not needed from the facility. The Administrator and S1 denied the allegation stating that medication have been provided to FR1 as prescribed. However, based on record review, LPA observed that on the Medication Administration Record for the month of July 2025 provided by the Administrator, FR1’s Metformin 1000MG of 1 tablet 2 times daily, the medication to be taken at 8pm from July 18, 2025, to July 22, 2025, was not initialed by staff. The Administrator stated that the Medication Administration Record provided was due to an error and also stated that there’s another Medication Administration Record that shows that that medication was provided on those dates. LPA requested to see that document. However, the Administrator did not provide the document to confirm that Metformin was given on the date of July 18, 2025, to July 22, 2025, at 8pm during the visit. Therefore, there was sufficient supportive evidence to concur with the reported allegation.


Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D.

An exit interview was held with the Administrator, Kaylon Hallman, and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250731140624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVELYN'S MANOR
FACILITY NUMBER: 198603798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2025
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465 (a)(4) Licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The administrator will submit a plan on re-training the staff on medication management and will retrain staff that pass out medications and will submit training materials and sign in sheets discussed by the POC due date.
Daniel.Konishi@dss.ca.gov
8
9
10
11
12
13
14
Based on interview and record review, LPA observed MARs (Medication Administration Record) for FR1 was missing initials for Metformin 1,000MG of 1 tablet at 8pm from July 18th, 2025, to July 22nd, 2025, and that Former Resident #1 (FR1) stated not receiving medication for hypertension for three to four days which poses an immediate health, safety or personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2025 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250731140624

FACILITY NAME:EVELYN'S MANORFACILITY NUMBER:
198603798
ADMINISTRATOR:HALLMAN, KAYLONFACILITY TYPE:
740
ADDRESS:1126 E 82ND STREETTELEPHONE:
(310) 739-9303
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY:6CENSUS: 2DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kaylon Hallman, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate food service.
Staff do not ensure resident hygiene needs are met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Daniel Konishi conducted an initial 10-day complaint visit in regards to the allegation listed above. LPA explained the purpose of the visit to Kaylon Hallman, the Administrator for the facility that assisted with the visit.

The investigation consisted of the following: LPA obtained copies of Staff Rosters, Resident Rosters, Weekly Menu, Diabetic Meal Plan. and Resident #1 (R1) files such as: Physician’s Report, Daily Shower logs (July 2025), Medication Administration Record (July 2025). LPA toured the facility's kitchen. LPA interviewed the Assistant Administrator, Staff #1 (S1) and Former Resident #1 (FR1), Resident # 1 (R1), and Resident #2 (R2).

The investigation revealed the following: in regards to the allegation “Staff did not provide adequate food service.” It is alleged that the staff only provides one meal daily that consists of sausage.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250731140624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EVELYN'S MANOR
FACILITY NUMBER: 198603798
VISIT DATE: 08/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interview, the FR1 corroborated with the allegation stating that the facility only provided the same one meal consisting of sausage. Based on resident interview, two (2) out of (2) residents denied the allegations stating that three meals are provided daily and that there are provided a variety of meals and also mentioned that there was not a time where they were served only sausage or only one meal daily. Based on staff interview, the Administrator and S1 denied the allegation stating that three meals are provided daily. Based on record review, LPA reviewed the facility’s weekly menu which shows three daily meals are provided with a variety of protein such as chicken, beef, and fish. Based on observation, the facility has sufficient food supply including a minimum of 2 days perishable and 7 days non-perishable. The facility kitchen is clean and well-kept and in a operable condition. The food are properly stored in the refrigerator to avoid cross contamination. The freezer had a variety of protein such as chicken, beef, and microwaveable meals. Per Administrator, there are no residents who requires a modified diet that's prescribed by the doctor. There is not enough supportive evidence to concur with the reported allegation.

Allegation: “Staff do not ensure resident hygiene needs are met.” It is alleged that the staff are not providing residents showers. Based on resident interview, FR1 and one (1) out of two (2) residents denied the allegation stating that the facility staff did help provide assistance with showers. One (1) out of two (2) residents stated being able to independently take showers and not needing any staff assistance. Two (2) out of two (2) residents also stated not witnessing nor have any concerns of any residents’ hygiene not being met. The Administrator and S1 denied the allegation stating that they provided shower assistance for FR1 when FR1 resided at the facility. Based on record review, LPA reviewed FR1’s daily shower logs from July 18th, 2025, to July 31st, 2025, and showers were provided by 8am. The Administrator and S1 also stated that they continue to provide daily shower assistance at the facility. There is not enough supportive evidence to concur with the reported allegation.

Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was held, and a copy of this report was provided to the Administrator, Kaylon Hallman.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5