197606171-6-6-2022-28-AS-MVAO-CFDNMF-20220614103502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 06/06/2022
Date Signed: 06/06/2022 12:02:09 PM

Substantiated

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
11/10/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20211110122839

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:	06/06/2022
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Maria Jacobo - Administrator		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Resident is threatening other residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Maria Jacobo Administrator and explained the reason for the visit.

The investigation consisted of the following: On 11/17/21 LPA Flores interviewed administrator, resident #1(R1),#2(R2),#3(R3),#4(R4), requested staff/resident roster, incident reports for the last month, face sheets, physician's reports, medication sheets, and needs/care appraisal. On 6/6/22 LPA Flores requested a copy of current resident/staff roster, interviewed staff #2(S2),#3(S3),#4(S4),#5(S5), Resident #5(R5),#6(R6), #7(R7),#8(R8), and requested copies of R5,R6,R7,R8 identification and emergency sheet, physician's report, medication sheets, needs/care appraisal, and incident report dated 12/21/21.

(CONTINUED ON LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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-20211110122839

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: 06/06/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident is threatening other residents. It is alleged R1 tried to throw a bottle at R2 and that R1 was going to harm R2. Interviews with residents revealed 5 out of 8 residents interviewed stated to have observed residents get into verbal arguments and residents use threats toward other residents during those verbal arguments and staff have not intervene on such instances. 2 out of 8 residents have not observed residents involved in verbal arguments or residents threatening other residents. 1 out of 8 residents refused to be interview. Interviews with staff revealed 4 out of 5 staff interviewed have observed residents involved in verbal arguments but no threats have been heard. 1 out of 5 stated to have not observed residents get into any arguments. 5 out of 5 staff stated to intervene and/or notify the office staff when residents are observed engaging in arguments. Administrator stated steps are taken when such behaviors are not resolved after speaking with the residents. Documents reviewed revealed 8 out of 8 residents are ambulatory. 5 out of 8 residents required assistance with handling medication and 3 out of 8 residents handle their own medication. Medication sheets for the 5 residents receiving assistance show resident were taking their medications daily. Incident reports revealed, R1 went out to hospital on 11/17/21 and choose not to return to the facility and R2 went out to the hospital on 12/21/21 and R2's family decided that upon discharge R2 will move to a facility closer to family.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found Substantiated. California Code of Regulations Title 22,
Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Maria Jacobo Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211110122839

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/13/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will provide in-service training to staff and residents on section 87468.1 and submit a copy of the agenda and sign in log to the department by 6/13/22.
	8 9 10 11 12 13 14	Based on interviews conducted licensee did not ensure residents are not threating at facility as 5 out of 8 residents have observed residents threating other residents which poses an immediate health, safety, or personal rights risk of persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

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