197606170-6-21-2022-11-AS-UCOL-CGQNWV-20220727105012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:28:30 PM

Unsubstantiated

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
06/16/2022 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220616153521

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:	06/21/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Judith Muro, Asst. to Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident self harmed while in care.
Staff did not administer resident's medication as prescribed.

INVESTIGATION FINDINGS:

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On 06/20/2022, Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation to address the allegations listed above. LPA Agard met with Magdalena "Maggie" Romero, Asst. Admin and explained the purpose of this visit is to gather information for the complaint and deliver findings.

On 06/20/2022, the investigation consisted of the following: LPA Agard conducted a tour of the facility grounds, interviewed staff, residents, witnesses, and reviewed records. LPA Agard requested the following documents, which were received at the time of first visit: 1) A copy of the staff roster, 2) a copy of the resident roster, 3) Needs and services plans for R1, 4) physician report for R1, 5) Medication Administration Record for facility, Re-habilitation, and Hospital, 6) Any incident reports.

On 06/21/2022, LPA delivered findings.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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-20220616153521

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: 06/21/2022

NARRATIVE

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The investigation revealed the following: Regarding the allegation: Resident self-harmed while in care. “It’s being alleged that a resident tried to kill themselves due to not receiving psych meds.” 4 out of 4 staff states that a resident tried to harm themselves but not due to an error in medication administration. On 06/20/2022 at 10:10am S1 states, “yes there was a resident that recently tried to harm themselves, but we didn’t know nothing. We didn’t see any signs. R1 cut both their wrist with a knife. They came downstairs and showed the staff their wrist. Residents are not allowed to bring those things in the facility. R1 is independent in the community, so we don’t know where they got the knife from. There was no history of suicide prior with this resident.” On 06/20/2022 at 10:22am S2 states, “I think it was Tuesday the 14^th I saw R1 between 11:30am and 12pm. I asked them how they were feeling, and they reported feeling well. In the evening, R1 came for medication after being called several times. R1 showed their wrist to the staff. The staff called 911 and 911 came. We had no prior information on the resident being suicidal or self – injurious.” On 06/20/2022 at 10:39am, S3 states “R1 didn’t mention anything. They were always quiet, and never mentioned anything about wanting to commit suicide or kill themselves.” On 06/20/2022 at 3:04pm S4 states “the cuts were not bleeding when R1 showed me. It had been dried by the time they got downstairs and showed me. R1 cut horizontally across both wrists. I called 911 right away.” During interviews with the resident, 5 out of 6 could not confirm the allegation to be true. R1 was unavailable for an interview. All residents denied knowing R1 or any residents that recently tried to harm themselves. On 06/20/2022 at 11:01am R2 states, “Things are okay living here it’s better than the last place I was at before. I don’t know about any residents trying to harm themselves.” On 06/20/22 at 11:05am R3 states, “Oh I like it here. I like living here. There hasn’t been anyone recently that tried to harm themselves. Maybe a long time ago but nothing recent.” On 06/20/2022 at 11:16am R6 states, “I like living here. I’m happy. I don’t know about any residents trying to harm themselves. I don’t know R1.”

Regarding the allegation: Staff did not administer resident's medication as prescribed. It’s being alleged that a resident was not getting their medication as prescribed. 4 out of 4 denied this allegation to be true. On 06/20/2022 at 10:10am S1 states, “yes, they have been receiving their medication as prescribed. No doses have been missed; they were on top of that. We are the ones that dispense the medication.” On 06/20/2022 at 10:22am S2 states, “R1 had been taking their medications as prescribed. No doses were missed. We are the ones dispensing meds. The resident was hospitalized on May 4^th due to an issue with their diabetes. That
Cont on 9099C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220616153521

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: 06/21/2022

NARRATIVE

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could have been where the changes took place, but they did not take place with us. We did not make any changes to their medication, we just followed what was given to us from the hospital and rehabilitation center. R1 could be on the same medication but may just have a different name. I know that we did not make changes.” On 06/20/2022 at 10:39am, S3 states, “R1 has never missed medication. They are not in control of dispensing their medication.” During interviews with residents, 5 out of 6 couldn’t confirm this allegation to be true. R1 was not available for an interview. All residents state they receive their medication without issue. On 06/20/2022 at 11:01am R2 states, “they help me with my medication, and it is given to me properly without any issues.” On 06/20/22 at 11:05am R3 states, “they help me with my medication, and they are very good about it. They give it to me on time and don’t miss it. They call us to come every time.” On 06/20/2022 at 11:16am R6 states, “they give me medication in the morning and night. They do a good job. They never miss any medication. If you do not come, they will call you.”

LPA reviewed the following facility and resident records: On or around 04/13/2022, R1 was appraised by Golden Manor Rest Home. The appraisal indicates resident to be independent in most activities of daily living with the exception of medication administration. A review of R1’s physician’s report does not indicate a history of suicidal ideation or self-injurious behavior. On or around 04/13/2022 R1 arrived at Golden Manor Rest Home with the medication administration records from Regency Manor, their previous facility. It included the missing psychotropic medication referred to by the reporting party. On or around 05/04/2022, per an incident report, R1 was transported to the hospital due to a hyperglycemic episode. On or around 05/09/2022, per order summary from Grand Park Convalescent, R1 was transferred to a rehabilitation facility. A review of the order summary report dated 05/25/2022 indicates a change in medication and the missing psychotropic medications observed on the records from Regency Manor. On or around 06/02/2022, per a copy of the current medication list, dated and signed by R1 indicates an additional change in medication. R1 returned to Golden Manor Rest Home with a current medication list that was being followed by the facility. The current medication administration records indicate the missing psychotropic medication referred to by the reporting party. Per a review of current medication administration records, there were no changes to R1’s medication by the current facility. LPA did not observe any dosages missed.

Based on LPA’s observation, interviews conducted, and 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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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