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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:44:58 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
09/14/2021 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210914155658
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: 54DATE:
02/16/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Judith Muro, Personal AssistantTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff had an inappropriate sexual interaction with resident
INVESTIGATION FINDINGS:
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On 02/16/2022 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegation. LPA Agard met with Judith Muro, Personal Assistant and explained the purpose of this visit was to gather information regarding this complaint.

The investigation consisted of the following: on 09/15/2021 Licensing Program Analyst (LPA) Troy Agard initiated a 24-hour complaint investigation for the allegation listed above. LPA Agard met with Christina Revolorio, Medical Technician, and the purpose of the visit was explained. LPA toured the physical plant. Due to time constraints, interviews were conducted at a later date. The following documents were requested: Current Resident Roster, Current Staff Roster, Staff roster from July 2021, requested documents were due to LPA by Wednesday, September 22nd, 2021. On 12/27/2021 interviews were conducted.

On 2/16/2021 LPA delivered findings
Cont. on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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 2
Control Number 11-AS-20210914155658
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: 02/16/2022
NARRATIVE
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Regarding the allegation: Staff had an inappropriate sexual interaction with resident. It’s being alleged, in mid July 2021, a former staff, came to do work in a residents’ room. The resident was cornered by staff, groped, and inappropriate acts were performed. The investigation revealed the following: During interviews with residents 4 out of 5 deny having inappropriate interactions with current and previous staff. R2 states, staff generally do not interact with him or touch him inappropriately. R3 states, the staff treat him well. “Yes, they do.” He denied any staff having inappropriate interactions with him. “No”. R5 denied the allegation stating, “Not at all”. R1 states they were touched in appropriately by a former staff. “S4 was standing in a way that indicated I was about to be molested. I have been in trouble before, so I knew what that look meant. I never reported it because I was afraid that something would come back to me. I didn’t call you people. Someone called for me.”

During interviews with staff, the investigation revealed the following: S1-3 all denied the allegation to be true. S1 states, R1 keeps to themselves mostly and is under psychiatric care. R1 has a history of saying things that are not truths. R1 has in the past made false allegations against a Medical Technician. S1 states R1 alleged the staff had something against them because they’re transgender. S1states, S4 has worked at the facility for a few years. “They resigned voluntarily due to finding a better paying job.” S2 and S3 both states, not being made aware of any inappropriate sexual interaction between a resident and staff. “Honestly, with me, R1 doesn’t report anything. They never reported to me that anyone touched them inappropriately.” S4 was unavailable for an interview.

During a review of the investigation conducted by Investigation Bureau (IB), the following was revealed: IB during an interview with R1, R1’s description of events was inconsistent, and the alleged perpetrator last name did not match. IB states, “During my interview with R1, the information provided change multiple times. When I asked follow-up questions, the information would change again. During my interview I found R1’s statement to not be credible.” During an interview with S4, IB states in summary S4 denied any involvement with R1 and was warned by staff to never go into R1’s room due to their history of false allegations against personnel. During an interview with S5, IB states in summary being told S4 no longer worked at the facility due to recently returning back to their previous employer. S5 states, “R1 has a history of making false allegations and no staff members are allowed in R1’s room.”


Based on LPA’s observation, interviews conducted, record review, 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 the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC9099 (FAS) - (06/04)
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