197606171-3-29-2022-28-AS-WSHO-CDDT2B-20220411142027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:49:49 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 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
03/08/2022 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220308100453

FACILITY NAME:	GOLDEN MANOR RETIREMENT CENTER		FACILITY NUMBER:	197606171
ADMINISTRATOR:	MARIA JACOBO		FACILITY TYPE:	740
ADDRESS:	1109 WEST BEVERLY BLVD.		TELEPHONE:	(323) 724-3870
CITY:	MONTEBELLO	STATE: CA	ZIP CODE:	90640
CAPACITY:	160	CENSUS: 76	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Maria Jacobo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff is financially abusing resident while in care.
Staff left resident soiled for an extended period of time.
Staff did not safeguard resident's personal items.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Maria Jacobo and explained the reason for the visit.
The purpose of the visit is to deliver the findings from the original complaint dated 3/8/22.
At initial visit the following was done:
Resident #1's file was reviewed at 1:15 PM.
On 3/17/2022 from 2:00 to 3:00 PM Resident's # 1-6 and Staff Maria Jacobo, Robert Blanco and Fernando Castillo were interviewed.
Physician for Resident #1 was interviewed at 1:40 PM.
In regards to the allegation Staff is financially abusing resident while in care, based on review of financial records the facility did deposit into an account for Resident 1 the amount of $1200 on 6/3/2020 and $1400 on 4/7/21 which were the amounts for the different stimulus payments. From 6/15/21 to 12/3/21 withdrawals for Resident #1 were made totaling $1887.
Administrator had stated that payments had been made to Resident #1 a year ago and were kept by home

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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 28-AS-20220308100453

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: 03/29/2022

NARRATIVE

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office and the resident will make weekly withdrawals.
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.
In regards to the allegation Staff left resident soiled for an extended period of time, based on interviews conducted and information gathered Physician's Report dated 1/5/22 stated that Resident 1 can care for his own toileting needs and is able to leave the facility unassisted.
Interview conducted with Medical Doctor for Resident 1 stated that he considers him independent and has never seen him incontinent.
Stated he is on Oxybutin to control the bladder.
Review of the Medication Log shows that Oxybutin 5mg. had been administered for morning and evening dose and there were no doses missed.
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.
In regards to the allegation Staff did not safeguard resident's personal items, based on interviews conducted and information gathered staff interviewed stated that any clothes brought into the facility for residents are put on an inventory list.
Admission Agreement states that facility will only inventory and provide the resident or responsible party with a copy of the resident's personal properties/valuables as inventoried items if said items are entrusted to the facility and are stored in a secured area.
Based on interviews conducted clothes that were reported missing had not been entrusted with the facility and inventoried.
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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

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