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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 12/23/2022
Date Signed: 12/23/2022 11:59:20 AM

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
12/19/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221219122950
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: 71DATE:
12/23/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria JacoboTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff are forcing resident to take medicine.
Staff are withholding resident's money.
INVESTIGATION FINDINGS:
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5
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8
9
10
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12
13
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 conduct a 10 day complaint visit in regards to the above allegations.
At today's visit the following was done:
On 12/23/2022 from 9:45 AM to 11:15 AM Administrator, Staff S1 and Resident's 1-8 were interviewed.
Resident and Staff Roster submitted.
File was reviewed for Resident R 9 and Medication Sheet and Physician's Report submitted for Resident R 9.
In regards to the allegation Staff are forcing resident to take medicine, based on interviews conducted and information gathered it was revealed that 8 of 8 residents that were interviewed all have been administered their medication correctly without error and have never been forced to take medication.
Stated staff have done a good job and get it correct all the time. Residents interviewed range from 5 to 14 years residing at the facility.


Unsubstantiated
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: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
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-20221219122950
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: 12/23/2022
NARRATIVE
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Staff interviewed stated that medication has always been given correctly and they have never forced any
resident to take medication.
Documentation from the Medication List for R 9 shows from 12/1-12/22 that R 9 has refused medication.
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 are withholding resident's money, based on interviews conducted and information gathered it was revealed that 8 of 8 residents that were interviewed all stated that on the 1st of the month they have received $154 and the facility has always given that amount without missing and without error. Residents interviewed range from 5 to 14 years residing at the facility.
Staff interviewed stated that $154 is always given the 1st of the month and there have been no errors.
Stated that R 9 has always received the $154.
Administrator provided copies of R9's monthly checks from County of Los Angeles Public Administrator in the amount of $1231.77 and $154.
Client/Resident Cash Sheet was observed with signatures of residents receiving the monthly $154.
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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2