197606171-9-7-2023-28-AS-RORN-CVLTKW-20230912144838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:56:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/08/2021 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211208141338

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: 73	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Cramen Virrueta - Assistant Administrator		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Facility did not follow mask use guidelines.
Facility staff did not have adequate PPE.
Facility is not cleaning and disinfecting as needed to prevent spread of infection.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to investigate the above allegations. Upon arriving at the facility, LPA met with Assistant Administrator - Carmen Virrueta and Administrator Maria Jacobo who later assisted with the visit, the purpose of today’s visit was explained.

The investigation consisted of the following:
On 12/16/2021 LPA Glenn Trueman conducted the initial visit and interviewd 3 Staff, due to insufficient information available at the time further investigation was needed.

During todays visit LPA Herrera obtained the following documents: Resident/Staff Roster, Infection Control Plan, Covid-19 Mitigation Plan Report, and training logs for ongoing Covid training. Observed sinage thoughout the facility for disinfection, cough ettiquette, and hand washing procedures, along with a storage room filled with PPE supplies that included: masks, disposible gowns, face shields, gloves, hand sanitizer, and antigen Covid tests. Interviewed 8 Residents and 5 Staff (all of which were living/employed at facility during pandemic). (Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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 3

Control Number 28-AS-20211208141338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR RETIREMENT CENTER	FACILITY NUMBER: 197606171
	VISIT DATE: 09/07/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Facility did not follow mask use guidelines.
It is alleged that at the time the order was given to wear masks at all times residents were not prompted to do so, only time they were was when taking a Covid test. Review of training logs showed ongoing training of Covid guidelines for mask use. During interviews with Staff 5 out of 5 Staff stated that during the Covid period staff tried their best efforts to mandate the masking requirements, although sometimes residents would not wear their masks and give some push back, Staff would continuously remind them to put on their mask and wear them properly at all times, after the reminders the residents would cooperate. During interviews with residents 8 out of 8 residents denied the above allegation and stated that they were constantly encouraged and reminded to wear masks and if a resident wasn't wearing a mask staff would ask them to put one on or provide them with a mask and have them put it on.

Allegation: Facility staff did not have adequate PPE.
It is alleged that PPE supplies was not readily available until after a quarantine was issued. LPA observed the PPE supply during todays visit, there was a storage room that had cabinets filled with masks, gowns, shield, gloves, Lysol and hand sanitizer. LPA interviewed Staff and 5 out of 5 Staff all stated that the facility has maintained sufficient PPE supplies since the start of the pandemic and that supplies were provided regularly by the city, licensing and purchased by facility as well. Staff also stated that there were PPE supply stations throughout the facility so that it was readily available when needed, and would be refilled when running low. During interviews with Residents 8 out of 8 residents interviewed denied the above allegation. Residents interviewed stated that they never had issues with getting any masks or sanitizer during that time or now, they also stated that masks were always readily available and if they didn't have a mask or other PPE supplies they could ask for some at the front desk and supplies were provided right away.

Allegation: Facility is not cleaning and disinfecting as needed to prevent spread of infection.
It is alleged that there is insufficient deep cleaning and disinfection done at the facility. LPA interviewed 5 Staff and 5 out of 5 Staff stated that the cleaning was increased once the pandemic hit, disinfection and cleaning was done hourly and even in-between as needed, and staff are still practicing the disinfection procedures. Review of training logs showed ongoing training of Covid guidelines for disinfection and
(Continued on 9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211208141338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR RETIREMENT CENTER	FACILITY NUMBER: 197606171
	VISIT DATE: 09/07/2023

NARRATIVE

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cleaning. LPA interviewed 8 Residents and 8 out of 8 denied the above allegation and stated that they noticed Staffs increase of cleaning and disinfecting. Residents interviewed stated they feel that staff was cleaning all the time and all throughout the day.

Based on statements and interviews conducted with staff and residents, and review of training and Infection Control Plan, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Administrator Maria Jacobo.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

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