197606170-12-16-2024-11-AS-EMAZ-DDSU7G-20250211141954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606170
Report Date: 12/16/2024
Date Signed: 12/16/2024 04:49:11 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, 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
12/06/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20241206094824

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: 65	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Magdalena Romero		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not treat resident with dignity and respect.
Staff did not ensure resident received prescribed medication.

INVESTIGATION FINDINGS:

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On 12/16/24, the department conducted an unannounced subsequent complaint visit to the facility listed above. The department met with Office Assistant, Magdalena Romero, and the purpose of today’s visit was explained.

During today’s visit, the department interviewed Residents R1-R7, interviewed Staff S2 and S6, and received staff In-Service Training Logs.

During a previous visit on 12/13/24, the department toured the facility, interviewed Staff S1, S3-S5, reviewed five (5) resident’s medications, and received documents pertinent to the investigation. The following documents were received and reviewed: Staff Roster, Resident Roster, Resident Physician’s Report, Centrally Stored Medications, Medication Administration Record (MAR), and Admission Agreement.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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 4

Control Number 11-AS-20241206094824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR REST HOME	FACILITY NUMBER: 197606170
	VISIT DATE: 12/16/2024

NARRATIVE

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Allegation: Staff did not treat resident with dignity and respect.
The complaint allegation alleges that when a resident requested an item the staff tells them “I don’t have time for that." Additionally, it is alleged staff said a resident requested something inappropriate when they didn’t.
During the facility tour, the department observed residents Personal Rights posted in the hallway near the office.
During record review, the department received and reviewed staff In-Service Training Logs. On 01/03/24, 05/16/24 and 11/18/24 Resident Rights was a subject reviewed and discussed in the in-service.
During interviews with Staff S1-S6, were asked if residents are treated with dignity and respect, six (6) out of six (6) stated residents are treated with respect and dignity. Additionally, Staff were asked if they have or have heard staff speaking inappropriately to residents, six (6) out of six (6) stated no they have not nor have they observed it.
During interviews with Residents R1-R7, were asked if they are treated with dignity and respect by the staff, six (6) out of seven (7) stated yes, staff treat them with dignity and respect. One resident stated most of the staff treat them with respect and dignity. Additionally, residents R1-R7 were asked if staff have spoken inappropriately to them, four (4) out of seven (7) stated staff have not spoken inappropriately to them. Two residents declined to state, and one stated most of the staff do.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20241206094824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR REST HOME	FACILITY NUMBER: 197606170
	VISIT DATE: 12/16/2024

NARRATIVE

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preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not ensure resident received prescribed medication.

The complaint allegation alleges that staff delivered a resident’s nighttime medications late.
During record review, the department received and reviewed staff In-Service Training Logs. On 02/13/24, 03/13/24, 04/16/24, and 11/18/24 Medication Policies was a subject reviewed and discussed.
During the facility visit, the department observed the med tech prepare and dispense medications to the residents. Additionally, the department reviewed Centrally Stored Medications and Medication Administration Record (MAR) for five (5) residents and found five (5) out of five (5) resident’s medications are consistent with properly documented records.
During interviews with Staff S1-S6, were asked if residents receive their medications as prescribed, six (6) out of six (6) stated yes, they give medications as prescribed.
During interviews with Residents R1-R7, were asked if they receive their medication as prescribed and on time, seven (7) out of seven (7) stated they receive their medications as prescribed and on time.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20241206094824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR REST HOME	FACILITY NUMBER: 197606170
	VISIT DATE: 12/16/2024

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	During the time of visit the department did not observe or cite any deficiencies. An exit interview was conducted with Office Assistant, Magdalena Romero, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

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