197606170-7-23-2020-11-AS-MVAO-BSFM8D-20200813092254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 07/23/2020
Date Signed: 07/23/2020 06:09:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2020 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200630085934

FACILITY NAME:	GOLDEN MANOR REST HOME		FACILITY NUMBER:	197606170
ADMINISTRATOR:	MARK INGBER		FACILITY TYPE:	740
ADDRESS:	3535 OVERLAND AVENUE		TELEPHONE:	(310) 836-0510
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	98	CENSUS: 64	DATE:	07/23/2020
		UNANNOUNCED	TIME BEGAN:	11:33 AM
MET WITH:	Mark Ingber, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility has rodents

INVESTIGATION FINDINGS:

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On 7/23/20 at 11:33 AM, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings for the above allegations. Due to the situation surrounding the coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation findings was conducted telephonically with Mark Inger, the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 7/2//2020 at 10:45 am, Licensing Program Analyst (LPA) Martessa Brown met with Administrator Mark Inger. During the visit LPA toured the physical plant, resident’s rooms and outside area. LPA conducted telephone interviews between 11:30 am and 2:15 pm with administrator and assistant, staff S1-S3. LPA requested copies from the administrator of the following records, residents R1-R3 files, most recent physician report, individual needs and service plan, admission agreements, residents and staff roster, facility floor plan sketch, house rules and 6 months of pest control records via email.
Coninuation of LIC9099-C is on the next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200630085934

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR REST HOME	FACILITY NUMBER: 197606170
	VISIT DATE: 07/23/2020

NARRATIVE

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The investigation revealed the following:

Regarding the allegation: Facility has rodents

On 7/2/20 LPA interviewed the administrator and the assistant over the telephone regarding the above allegation, Administrators stated they did not see, nor any residents complained to them of seeing rodents in the facility. They stated the company pest control Western Exterminators comes twice a month and conducts preventive measure. LPA asked the administrator if residents go to the basement? He stated they would not have a need to go down there and only staff is permitted. He also stated residents do not eat in their rooms in the but are in the dining room area at stager times. LPA asked administrator, how often does housekeeping clean? He stated housekeeping cleans the facility every day and deep cleans twice daily. LPA Interviewed Staff members S1-S3 over the telephone, all staff members indicated they have not seen any rodents at the facility nor have any residents complained to them about rodents. LPA asked staff how often does pest control come to the facility? Staff stated they see pest control at least twice a month. Staff also stated housekeeping cleans daily and deep cleans.

On 7/10/20 LPA interviewed residents over the telephone regarding the above allegation, LPA tried to interviewed resident #R1 but she refused to talk to me. Residents #’s R2-R3 stated they had seen a dead rat on two separate occasion. Residents stated had saw one on the patio and another inside the facility but could not recall the dates. Residents #’s R4-R7 stated have not seen any rodents nor had anyone complained to them. LPA asked residents, if they go down to the basement? Residents stated they do not have a need to go into the basement.

Based on interviews and documentation during the investigation Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated or unfounded

A telephonic exit interview was conducted with Administrator, and hard copy was provided via email for records

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2020

LIC9099 (FAS) - (06/04)

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