197606170-2-16-2022-11-AS-AJKK-CD3S28-20220401132909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:43:56 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
02/08/2022 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220208123725

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: 54	DATE:	02/16/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Judith Muro, Personal Assistant		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide resident transportation for medical services.
Staff intimidates resident in care.

INVESTIGATION FINDINGS:

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On 02/16/2022 Licensing Program Analyst (LPA) Troy Agard conducted an initial 10-day complaint investigation at the above facility to address the following allegations. 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: LPA toured the physical plant, conducted interviews with staff, and residents. The following documents were requested: current resident roster, current staff roster, and any discharge paperwork for hospitalizations. Requested documents are due to LPA by Wednesday, February 23, 2022.

On 2/16/2021 LPA delivered findings.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (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)

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Control Number 11-AS-20220208123725

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 did not provide resident transportation for medical services. It’s being alleged a resident was sent to the medical center under false pretense. A staff falsely reported to paramedics that a resident was complaining of chest pain due to lack of transportation services at the facility. The investigation revealed the following: During interviews with staff, 3 out of 3 denied the allegation to be true. S1 states, “we have a sports utility vehicle (SUV) that can take resident’s to medical appointments. We are usually really good about that. We recently had a resident (R1) who was sent to the hospital due to having really swollen legs. We had to call 911 because we sent him to urgent care a few times before and they didn’t do anything for him. R1 was sent back for the same issue. S2 states they had been informed by housekeeping on 02/07/2022 that R1 was complaining of chest pains, but it was observed that R1’s legs were really swollen. “I called 911 because I had previously sent him to urgent care like 3 other times and they did nothing for him. I was concerned because his legs were red with bubbles. He complained to S3 that he had a lot of pain in the chest. I was concerned so I called 911. S3 states, observing R1’s legs really swollen. “It was really really bad. I checked in the morning with their breakfast. R1 said I have chest pains. I asked if they were okay. They said no, I have chest pain but nothing about the legs. I told S2 so they could check R1.”
During interviews with residents, 5 out of 6 denied the allegation to be true. R5 could not confirm the allegation to be true. “Yes, I go there, but I never use the facility’s transport. A lady from the Veterans Affairs (VA) comes to get me. R1-4 and 6 all deny having any issues with the facility transporting them to medical services. R1 states, “no I was not having chest pains. Someone made that up. I don’t know who made it up. I didn’t hear anybody say anything but when the paramedics arrived, they were after me for chest pains. S2 looked at my legs that were swollen and was upset. She called 911. My legs were retaining water and were swollen. They looked pretty bad.”

Regarding the allegation: Staff intimidates resident in care. It’s being alleged a staff member intimidates a resident and is fearful of retaliation from this staff member. The investigation revealed the following: During interviews with staff, 3 out of 3 denied the allegation to be true. S1 states, “no, they’re actually very good with the residents and always concerned with their well-being. S2 states R1 wanted to go. I never forced them to go because Emergency Medical Services (EMS) would refuse to take them. S3 denies S2 ever tries to intimidate residents.

During interviews with residents 4 out of 6 denied the allegation to be true. R2 states, “S2 is very nice to me I don’t have any problems with them.” R3 states, “S2 is incredible. Beyond nice to me and is incredibly competent. I don’t know what they would do without S2.” R4 states, “S2 is very good with me.” R1 states, “S2

Cont on 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (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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Control Number 11-AS-20220208123725

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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may try, but I don’t think so. S2 is kind of aggressive.” R5 states, “S2 is so so, sometimes she is aggressive and intimidates me. S2 treats just about everyone in here like that. They yelled at me this morning for no apparent reason.”

LPA reviewed copies of discharge paperwork which indicated resident R1 was sent for evaluation on 01/19/2022 for vitals check, on 01/25/2022 due to the swollen legs, on 02/04/2022 for heart failure symptoms and again on 02/07/2022.

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 Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (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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