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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 06/02/2020
Date Signed: 06/04/2020 11:58:57 AM



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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2020 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200526083801
FACILITY NAME:GOLDEN MANOR RETIREMENT CENTERFACILITY NUMBER:
197606171
ADMINISTRATOR:MARIA JACOBOFACILITY TYPE:
740
ADDRESS:1109 WEST BEVERLY BLVD.TELEPHONE:
(323) 724-3870
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY:160CENSUS: 109DATE:
06/02/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria JacoboTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Facility is not safeguarding resident's valuables
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Maria Jacobo, the facility administrator.
LPA Trueman conducted telephone interviews with the administrator, 8 residents, and 2 staff. The LPA also requested copies of various documents emailed to the LPA’s attention.
In regards to the allegation Facility is not safeguarding resident's valuables, based on interviews conducted with Staff at 10AM 6/2/20 and residents at 1050 AM 6/2/20 staff have been professional and have safeguarded residents valuables.
Residents interviewed and some living at the facility up to 9 years have had television, clothes and jewelry in room and have never had any items stolen.
Staff and residents interviewed stated that residents items are safeguarded and at times residents misplaced items that they thought were stolen and later found them.








Unsubstantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020
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 28-AS-20200526083801
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN MANOR RETIREMENT CENTER
FACILITY NUMBER: 197606171
VISIT DATE: 06/02/2020
NARRATIVE
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Resident 1 has not resided at the facility since 5/21/2020.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

A telephonic exit interview was conducted with Maria Jacobo , and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2