197606171-8-31-2020-28-AS-AJKK-BU6UMQ-20201007154244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 08/27/2020
Date Signed: 08/31/2020 12:41:24 PM

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
04/27/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200427123043

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: 109	DATE:	08/27/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Maria Jacobo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is verbally abusing resident while in care
Resident is being physically harmed by other residents while in care
Resident is being provided an unauthorized medication while in care
Resident is not being treated fairly while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Glenn Trueman initiated a follow up complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Maria Jacobo.
Initial visit was conducted on 5/4/2020 and the following was done:
LPA Rivas conducted telephone interviews with the Medication Technician Ms. Virretua. The LPA also requested copies of resident roster/register, LIC 500, medication Administration record for Resident #1(R1), copy of doctor's orders for R1 to be emailed to the LPA’s attention
On today's visit 8/27/2020 Resident's 2-7 were interviewed. Resident 1 has not resided at the facility since 6/27/20. Staff 1-3 were interviewed.
Copies of Emergency ID Page, Physician's Report, Medication Log and Needs and Services plan were submitted via e-mail.
In regards to Staff is verbally abusing resident while in care, 6 of 7 residents interviewed stated they had not heard staff verbally abuse any residents. Also stated that residents are tough on staff and provoke staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2020

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-20200427123043

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: 08/27/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff interviewed stated that staff had never verbally abused Resident 1 and that Resident 1 would often complain and would get upset if she was told to wait in line for food because others had been there and Resident 1 would be upset and want the food right then and there.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
In regards to the allegation Resident is being physically harmed by other residents while in care, interviews with 6 of 7 resident stated that they had not witnessed any resident harm another resident. They had witnessed some verbal hostility, but nothing physical. Stated that staff have been quick to respond.
Staff interviewed stated they have been quick to respond and no resident has ever been witnessed harming another resident.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
In regards to the allegation Resident is being provided an unauthorized medication while in care, interviews with 6 of 7 residents who stated that they have never had any difficulties with medication being administered to them. They have always been administered on time and never missed any doses.
Med-Tech interviewed stated that Resident 1 was only given what was administered by the doctor. Resident 1 would complain often for pain and would ask for more pills. Resident 1 had complained that medication was being changed and the Med-Tech had to explain that at times the pills were larger or had changed color.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
In regards to the allegation Resident is not being treated fairly while in care, 6 of 7 residents stated that all activities are posted on a monthly calendar and all are treated fairly to participate in cards, dominoes and bingo.
Staff interviewed stated that activity calendars are posted and announcements are made to all residents to participate in activities.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
It should be noted that resident 1 no longer resides at the facility since 6/27/2020.
Report e-mailed to facility for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2