197606170-9-6-2023-11-AS-JHAD-CVLN7N-20230912101302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 09/01/2023
Date Signed: 09/06/2023 11:08:05 AM

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
08/17/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220817085015

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: 65	DATE:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	11:43 AM
MET WITH:	Magdalena Romero		TIME COMPLETED:	03:34 PM

ALLEGATION(S):

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Staff did not administer resident's medication as prescribed.
Resident was chemically restrained while in care.
Staff not making sure resident is given enough water.

INVESTIGATION FINDINGS:

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On 09/01/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit to the facility and was greeted by assistant administrator Magdalena Romero. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above.

The investigation consisted of the following: An initial complaint visit by LPA Alvizar on 08/23/22. Subsequent visits by LPA Dabuet & Cloyd on 08/25/23 and LPA Dabuet on 09/01/23. LPAs investigated the allegations mentioned in this complaint; and conducted interviews with residents, staff, and witnesses. Staff rosters, Resident rosters, Incident Reports, Physician's Reports, Appraisals/Needs and Services Plans, Medication Records, Progress Notes for resident #1 (R1), and other pertinent records associated with this complaint. A tour of the facility was conducted.

(Evaluation Report continues LIC-0099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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 11-AS-20220817085015

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: 09/01/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not administer resident's medication as prescribed.
Resident was chemically restrained while in care.

The details of the complaint alleged staff did not administer medication as prescribed to resident #1 (R1) under chemical restraint, as reported on the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. Specifically, the complaint focused on an incident that occurred on 07/18/22 at Golden Manor Rest Home. The Department reached out to the complainant for further comments but was not available.

The (SOC 341) described resident #1 (R1) was admitted on 06/26/22 at Grand Park Convalescent Hospital (GPCH) where (R1) recovered from (R1’s) primary medical condition and was discharged on 07/18/22. On 07/18/22 (R1) reentered at Golden Manor Rest Home (GMRH). A few hours after being admitted back at Golden Manor Rest Home, (R1) collapsed and was taken to Daniel Freeman Hospital for weakness and was evaluated with dehydration.

The complainant reported in the (SOC 341) (R1) was administered medication that was not prescribed and that (R1) had been treated for a bladder infection when (R1) returned on 07/18/22 to the Golden Manor Rest Home. In addition, it was reported on (SOC 341) that (R1) may have been over-sedated with medications on 0718/22.

In (R1)'s medical records, from 06/20/22 to 10/22/22, (R1) transitioned between hospitals, skilled nursing homes, and Golden Manor Rest Home. As a result of these transitions, (R1’s) medications have remained consistent. According to Medication Administration Records for (R1), medications were taken daily, and no medications were missed or refused. There were no non-prescribed medications issued by (GPCH) or (GMRH). There were (13) of (15) medications prescribed by (R1’s) medical physician such as Lorazepam, Benztropine, Divalproex, Tamsulosin, and Fluphenazine all have side effects that may result in prostate and urinary tract issues according to the National Institute of Health (NIH).

On 08/25/23 from 1:30 pm – 2:30 pm the Department interviewed (7) out of (65) residents (R2-R7) and (6) out (7) reported needing assistance with medication management and (6) of (7) have not encountered issues nor have been provided medications that are not prescribed by medical physician.
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20220817085015

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: 09/01/2023

NARRATIVE

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According to (SOC-341) it stated resident #1 (R1) on 07/18/23 was discharged from Grand Park Convalescent where (R1) was treated from 06/26/22 through 07/18/22. On 07/18/22, (R1) returned to Golden Manor Rest Home at 10:45 am. During lunch while sitting in the dinning room, (R1) collapsed and was hospitalized was noted to have been dehydrated by the hospital.

Medical records for (R1), from period 06/20/22 through 10/22/22, (R1) transitioned in and out of hospitals, skilled nursing homes, and Golden Manor Rest Home. During these transitions, (R1’s) medications have remained the same. These prescribed medications such as Dilantin, Flomax, Keppra, and Restoril caused side effects of dehydration or dry mouth according to the National Institute of Health (NIH). In accordance with Medication Administration Records for (R1), medications were taken daily, and no medication was missed or refused.

On 08/25/23 from 1:30 pm – 2:30 pm the Department interviewed (7) out of (65) residents (R2-R7) and (6) out (7) reported having no concerns or issues nor having experienced any symptoms of dry mouth or dehydration. (6) of (7) confirmed there is no shortage of liquids as it is provided with meals, snacks, and medication intakes. Liquids are also available upon request when requested.

On 08/25/23 – 9:30 pm – 3:00 pm, the Department interviewed (4) out (19) staff (S1-S3) and reported residents are provided water with medications. A wide variety of juices, milk, coffee, and tea are available at all meals. There are liquid refreshments available during snacks or in the kitchen upon request. This source was verified by reviewing the facilities menu. During investigation visit on 09/01/23, the Department observed liquid refreshments were distributed to residents between 2:30pm - 3:30pm. (S1-S3) stated (R1) has never been limited or refused liquids.

On 08/30/23 from 10:20 am to 10:30 am, the Department interviewed the responsible party witness (W1) to resident #1 (R1). (W1) who is a frequent visitor to (R1) reported not to have observed (R1) in a dehydrated state. (W1) was complimentary of staff for the care and supervision provided for (R1).

(R1) was interviewed on 08/18/23, however (R1) is unable to communicate and carry on a conversation due to (R1's) health condition. A review of resident #1 (R1’s) Physician’s Report dated 01/30/2021, (R1) is capable of self-care and can feed self and follow instructions.

Based on the information gathered, there is no evidence to support the allegation mentioned above.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20220817085015

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: 09/01/2023

NARRATIVE

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On 08/25/23 – 9:30 am – 3:00 pm, the Department interviewed (3) out (19) staff (S1-S3) and reported residents are only given prescription medication prescribed by a medical professional. (S1) stated (S1) is the only staff that prepares medication for residents. (S1) follows procedures, monitors residents who refuses to consume liquids or food, and will contact the physician. (S1) will contact the resident’s physician when changes occur with the resident due to medications. (S1) reported there had been no changes in (R1’s) medication orders when (R1) was readmitted back at (GMRH) on 07/18/22. On 07/18/22, (R1) only received one tablet of Lorazepam at noon before collapsing and being rushed to Daniel Freeman Hospital.

A review of (R1’s) medication revealed (R1) is prescribed Lorazepam one tablet every 6 hours 7 am, 12 pm, and 8 pm, and Temazepam one capsule at bedtime. A mild to moderate level of sedation can be achieved with these medications, according to the National Institutes of Health (NIH).

On 08/30/23 between 10:20 am to 10:30 am, the Department interviewed the responsible party witness (W1) to resident #1 (R1). (W1) who frequently engaged with (R1) reported no issues or immediate concerns with (R1’s) consumption of medications. (W1) was aware of the type of medications that had been prescribed and what their side effects may cause for long-term use. (W1) claimed that (R1) had a prostate operation and would be prone to bladder issues with the type of medications that (R1) was prescribed daily. (W1) stated being fond of the staff and how that facility operates and hopes (R1) to be accepted back once (R1) has recovered from the skilled nursing home.

(R1) was interviewed on 08/18/23 however (R1) is unable to communicate and carry on a conversation due to (R1's) health condition. A review of resident #1 (R1’s) Physician’s Report dated 01/30/2021, (R1) required assistance taking medication. A review of (S1's) Med-Tech completed medication training courses. Based on the information gathered, there is no evidence to corroborate the allegations mentioned above.

Allegation: Staff not making sure resident is given enough water.

The details of the complaint alleged that resident #1 (R1) was not given enough water as reported in the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. It indicated that (R1) was dehydrated and did not have enough water. The Department reached out to the complainant for further comments and was not available.

(Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20220817085015

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: 09/01/2023

NARRATIVE

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Based on information gathered, an inspection of the facility, observation, and interviews conducted, analysis of service records and medical records, the Department found no evidence to support the allegations mentioned above.

Although the allegations 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 allegations is Unsubstantiated.

No deficiencies were cited.

An exit interview conducted with Magdelena Romero and a copy of the this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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