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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 09/12/2023
Date Signed: 09/12/2023 10:19:07 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
06/29/2021 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210629154733
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:
09/12/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maria JacoboTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Resident sustained injuries while in care.
Staff allowing residents access to medication room.
INVESTIGATION FINDINGS:
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The purpose of the visit is to add additional details to the 9099 A and 9099 D.
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 visit is a subsequent visit to investigate the above allegations and deliver findings.
The initial visit was conducted on 06/30/2021 and the following was done:
The purpose of the visit is to conduct a Health and Safety check.
Tour of the facility was conducted at 2:00 PM with LPA and Administrator and included the following:
1st floor rooms 1-32 and 2nd floor rooms 33-80, dining room, kitchen, activity room, library, med room, nurses room and 2 outdoor patios.
LPA Trueman conducted interviews with the Administrator and S 1 from 2:25 PM to 2:50 PM.
At today's visit 08/17/2023 from 8:45 AM to 9:15 AM Staff S 2- S 4 were interviewed.
From 9:15 AM to 10:40 AM Resident's R2- R 11 were interviewed.
In regards to Resident sustained injuries while in care, based on interviews conducted and information gathered interviews with 10 out of 10 resident's who all stated they had not witnessed or heard of staff
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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 5
Control Number 28-AS-20210629154733
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: 09/12/2023
NARRATIVE
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harming or injuring resident's in any way.
10 of 10 resident's stated that staff are doing a good job and carry out all their responsibilities and have not witnessed staff treating resident's badly in any way.
Staff interviewed stated that S 2- S 4 had gone to R 1's room to discuss the rent raise.
Stated that they had handed the letter to R 1 with the rent increase and R 1 was the one to cause injury by slamming the door on S 2's foot.
Law Enforcement did arrive at the facility and there were no charges against facility staff.
There is no evidence provided to support that facility staff caused the injuries to R 1.
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 allowing residents access to medication room, based on interviews conducted and information gathered 10 out of 10 resident's stated that staff does a good job assisting them with their medication.
Stated that the med-tech is in the med- room to assist with all their medications and that the resident's do not have access to the med room. All 10 stated staff is always there and if not the door is always locked.
Staff interviewed stated that resident's definitely do not have access to the med room and it is always locked or staff are in the med room.
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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/29/2021 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210629154733

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:
09/12/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maria JacoboTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
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8
9
Facility staff are harassing resident.
INVESTIGATION FINDINGS:
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The purpose of the visit is to add additional details to the 9099 A and 9099 D.
In regards to the allegation Facility staff are harassing resident, based on interviews conducted and information gathered interviews conducted with 10 out of 10 resident's who all stated they are aware of the rent increase and are aware of the rent increase letter that was sent.
All 10 of 10 stated that they have never had staff come to their room and discuss the rent increase with them.
Staff interviewed stated that they did go to R 1's room to discuss the rent increase.
Also stated that R 1 was unhappy when they did show the letter and spoke about the increase and wanted S 2- S4 to leave the room.
Staff stated that S 2 tried to put her foot in door to not leave the room when R 1 was closing the door and trying to get them to leave.
It should be noted that the date of the incident was 06/29/2021 and the facility submitted a Special Incident Report (SIR) dated 06/29/2021.


Substantiated
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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210629154733
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: 09/12/2023
NARRATIVE
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Rent was to be increased commencing 01/01/2021.
LPA observed facility letters of rent increase dated 11/01/2020, 02/16/2021, and 06/24/2021.
Interviews conducted revealed that Staff confirmed that Resident R 1 was the only resident that was informed by 3 staff in person.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation is 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210629154733
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: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2023
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities
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.

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Facility to review regulation regarding Personal Rights of Residents in All Facilities and conduct a staff training regarding personal rights and submit a signed log of those who attended by POC due date.
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This requirement is not met as evidenced by;
Based on interviews conducted licensee failed to ensure that resident's be accorded
dignity in their personal relationships with staff, with 3 staff harassing R1 by going to their room about the rent which poses a potential health, safety or personal rights risk to persons in care.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5