197606170-7-12-2024-11-AS-UCOL-D7Q2EX-20240731172040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 07/12/2024
Date Signed: 07/12/2024 02:56:48 PM

Unsubstantiated

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
07/10/2024 and conducted by Evaluator Mario Leon

COMPLAINT CONTROL NUMBER: 11-AS-20240710083320

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: 63	DATE:	07/12/2024
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Mark Ingber, Administrator		TIME COMPLETED:	03:08 PM

ALLEGATION(S):

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Staff is mismanaging resident's medications.

INVESTIGATION FINDINGS:

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On 07/12/2024 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Mark Ingber (S3), Administrator, and the purpose of the visit was explained.
The investigation consisted of the following:
On 07/12/2024 LPA requested and reviewed facility documents and toured the facility. LPA interviewed six (6) out of sixty-three (63) residents, four (4) out of twenty-four (24) staff and one (1) witness.
The investigation revealed the following:
Regarding the allegation: "Staff is mismanaging resident's medications.", it has been alleged that staff at the above-mentioned facility are not managing residents' medication appropriately. Between 09:10AM and 10:30AM, on 07/12/2024, LPA observed business in the Medication Room and interviewed staff one, Christina Revolorio and reviewed documents that were provided. Between 10:30AM and 2:00PM, LPA interviewed three (3) additional staff, one (1) witness, and six (6) residents.
Report continues, see LIC9099C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

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-20240710083320

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: 07/12/2024

NARRATIVE

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Interviews revealed that four (4) out of four (4) staff, six (6) out of six (6) residents and one (1) witness have denied the allegation has taken place. Record reviews have revealed that resident one (R1) has continued to receive all medications as listed on the Medication Administration Record for R1, and that interviews during LPA's visit have validated statements provided to LPA.

Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with Magdalena Romero, Assistant Administrator (S2), and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC9099 (FAS) - (06/04)

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