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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 08/05/2022
Date Signed: 08/05/2022 02:14:02 PM

Unfounded


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
07/28/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220728164752
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: 73DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator Carmen VirruetaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff sedated resident with meds causing resident to pass out
Staff not making sure resident is given enough water
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Assistant Administrator Carmen Virrueta and explained the reason for the visit.
The purpose of the visit is to conduct a 10 day complaint visit in regards to the above allegations.
At today's visit 08/05/22 at 9:30 AM S1 was interviewed. Staff S1 stated Resident R1 was not a resident at this facility and resides at another licensed facility.
LPA spoke with S2 staff at another licensed facility who confirmed that R1 is a resident at that facility. Resident Roster was submitted at today's visit and it does not list R1 as a resident. Based on interviews conducted and review of rosters it was determined that R 1 does not reside at this facility.
Based on the information gathered during this visit, the allegations are deemed UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
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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