197606170-10-23-2023-11-AS-UCOL-CYX248-20231227160332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 10/23/2023
Date Signed: 10/23/2023 02:50:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
10/17/2023 and conducted by Evaluator David Espana

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231017151357

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: 66	DATE:	10/23/2023
		UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Mark Ingber, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal items

INVESTIGATION FINDINGS:

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On 10/23/2023 at 11:18 am Licensing Program Analyst (LPA) David España conducted unannounced initial 10-day visit to the facility and purpose of a complaint investigation of the allegations listed above were explained. Licensing Program Analyst (LPA) David España met Magdalena Romero, Day Manager and Administrator, Mark Ingber. Upon arrival at the facility, LPA España conducted a risk assessment at the facility entrance. Based on the assessment, the facility is clear of Covid-19 infection. Today’s complaint visit was conducted with Magdalena Romero, Day Manager and Administrator, Mark Ingber.

The investigation consisted of following: Interviews and Record reviews. On 10/23/23, LPA obtained a copy of the current resident’s roster, staff roster, resident #1-#4 records. LPA España, toured the physical plant with Day Manager, interviewed R#1-R#4.

(Evaluation Report continues LIC-0099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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-20231017151357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR REST HOME	FACILITY NUMBER: 197606170
	VISIT DATE: 10/23/2023

NARRATIVE

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On 10/23/23, LPA obtained Resident and Staff rosters, R#1-R#4 file (ID/emergency information, Admission agreement, Physician's report, Needs and Services Plan, Mars). LPA obtained R#4 admission and discharge dates. LPA reviewed R#1-R#4 Preplacement appraisal information, Resident appraisal, Resident personal property and valuables files (June, July, August, September).

LPA requested and received the following documents and files for R#1-#4: Resident Roster, Staff Schedule R#1-5 (Face sheet, Physician's Report, Admissions agreement, Pre-Appraisal, Needs and Services Plan.) Documents were received at the time of visit. On 10/23/23 from 11:18 am – 2:50 pm the Department interviewed (4) out of (66) residents (R#1-R#4) and (4) out of (66) reported no issues with personal items missing. On 10/23/23 from 11:18 am – 2:30 pm the Department interviewed (5) out of (21) staff (S#1-S#5) and (5) out of (21) reported no issues with personal items missing.

Regarding Allegations: “Staff did not safeguard resident's personal items.”

The investigation revealed the following: Regarding the allegation “Staff did not safeguard resident's personal items.” 4 out of 4 resident interviewed disagreed with the allegation and denied having any issues with safeguarding of their personal items. 5 out of 5 staff (S#1-S#5) denied the allegation, S#1-S#5 denied not providing safeguard resident's personal items. Interviews conducted with S#1-S#5, stated that the staff if asked to safeguard residents’ personal items they are to sign documentation to safeguard resident’s personal items. Interviews conducted with R#1-R#4 stated they have never had problems with staff and notices concerning personal items.

In (R4)'s records show that, from 01/25/2007 to 07/11/2022, (R1) transitioned to the hospital from Golden Manor Rest Home. As a result of transition, (R1’s) medications did remain consistent per S#1. According to Medication Administration Records for (R#4), medications were taken daily, and no medications were missed or refused between 01/25/2007 to 07/11/2022. There were no non-prescribed medications issued by Golden Manor Rest Home per record review. Per record review #R4 has Scheophrenia Paranoid Disorganized per UCLA Family Health Center, 1920 Colorado Ave., Santa Monica, CA 90404.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231017151357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR REST HOME	FACILITY NUMBER: 197606170
	VISIT DATE: 10/23/2023

NARRATIVE

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Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated.

An exit interview was conducted, and a copy of the report was given to Administrator, Mark Ingber.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC9099 (FAS) - (06/04)

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