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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 08/13/2025
Date Signed: 08/13/2025 11:57:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250806090400
FACILITY NAME:GOLDEN MANOR REST HOMEFACILITY NUMBER:
197606170
ADMINISTRATOR:MARK INGBERFACILITY TYPE:
740
ADDRESS:3535 OVERLAND AVENUETELEPHONE:
(310) 836-0510
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:98CENSUS: 55DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Cristina RevolorioTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Licensee does not ensure that facility elevator(s) are in good repair.
INVESTIGATION FINDINGS:
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On 08/13/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit on to gather information regarding the above allegation. LPA met with Med-Tech Cristina Revolorio and the purpose of the visit was explained. LPA spoke with Administrator Mark Ingber over the phone.

Investigation consisted of the following: On 08/13/2025, LPA obtained Personnel Report (dated 04/16/25), Register of Residents, Resident #6-7's medical assessment, R6's Identification and Emergnecy Infor, and a business card of the former elevator company. LPA interviewed Staff #1 – 2 (S1-S2), Witness #1 – 2 (W1-W2), and Residents #1 – 7 (R1-R7), and observed the elevator. Note: LPA left a voicemail for W1 and R6 was unavailable.

Investigation revealed the following:
LPA observed an “out of service” notice on the elevator. Interview with the Administrator indicated that the elevator has been down for at least four weeks and the vendor is waiting for a particular piece. Continue to LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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 3
Control Number 11-AS-20250806090400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN MANOR REST HOME
FACILITY NUMBER: 197606170
VISIT DATE: 08/13/2025
NARRATIVE
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The Vendor (Witness #2) indicated that W2 anticipates the permit to be approved next week and the elevator to be completed in two months. Six out of six residents (R1 – R5, R7) agree with the allegation.

Regarding the allegation, “Licensee does not ensure that facility elevator are in good repair,” based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, plans of correction developed, and a copy of this report with the appeal rights was provided to the Administrator Mark Ingber.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250806090400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN MANOR REST HOME
FACILITY NUMBER: 197606170
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be... in good repair at all times...

This requirement was not met as evidence by:
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The Administrator will submit a plan of correction detailing the elevator contrsuction plan and project completion date, its impact on the residents, copy of notice sent to residents and authorized representatives, and copy of the permits to regina.cloyd@dss.ca.gov by the POC
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LPA observed an "out of service" notice on the elevator and interviews indicated that it has been out of services for at least four weeks which poses a potential safety risk to residents in care.
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due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3