<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 10/18/2022
Date Signed: 10/18/2022 02:43:09 PM

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
10/14/2022 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20221014092127
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: 66DATE:
10/18/2022
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:MAGDALENA ROMEROTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff withholding resident's money.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/18/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Facility Day Manager Magdalena Romero who stated the facility is free of Covid-19 infection. The purpose of the visit was explained.

The investigation consisted of the following: LPA Lourdes Montoya toured the facility with Facility Day Manager Magdalena Romero. LPA Montoya interviewed twelve (12) residents and five (5 staff). LPA requested copies of Resident #1’s service records and other pertinent records.

REPORT CONTINUED IN LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
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-20221014092127
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: 10/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Investigations Revealed:

Allegation: Facility staff withholding resident's money.

It is alleged that facility staff is withholding resident's money. LPA Montoya reviewed R1's service records and conducted interviews. Based on LPA’s review of Resident #1’s service records, R1 was admitted to the facility on 4/27/2019 and R1 is the responsible person for himself. S1 stated during interview that R1 is able to handle his own money and the facility does not handle R1's funds. LPA’s interview with Staff (S1-S5) and Residents (R1-R12) revealed they have not heard or observed any staff withholding resident’s money. R1 admitted no facility staff withheld his money. R1 stated he was confused. R1 rescinded his statement that a facility staff withheld his money. Based on interviews conducted, there is no sufficient evidence to corroborate the above allegation.

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.

A telephonic exit interview was conducted with Facility Day Manager Magdalena Romero, and a hard copy was provided.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2