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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 12/18/2025
Date Signed: 12/18/2025 12:20:56 PM

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
05/16/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250516113955
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: 79DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria JacoboTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not report resident's incident to appropriate parties
Staff failed to take action on change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff S1 and explained the reason for the visit.
Today's visit is a subsequent visit to conduct additional Interviews in regards to the above allegations.
Shortly thereafter Administrator Maria Jacobo arrived.
The initial visit was conducted on 05/23/25 and included the following:
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.
On 05/23/2025 Administrator Maria Jacobo was interviewed.
Staff S1 was interviewed.
Resident and Staff Roster submitted.
File was reviewed for Resident R 1 and VA Medication List, MAR Log for May 2025, Physician's Report , Special Incident Report (SIR) and ID page submitted.
At today's visit 12/18/25 interviews were conducted with Client's C2-C9.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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-20250516113955
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: 12/18/2025
NARRATIVE
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Interviews were conducted with the Administrator and Staff S1 and Staff S2.
In regards to the allegation Staff did not report resident's incident to appropriate parties, based on interviews conducted and information gathered LPA did receive Special Incident Report (SIR) dated 05/12/25 which states that at 9:15PM 05/11/25 Client C1 left the facility to go to a friends house and would return later.
Following day 05/12/25 C1 had not returned back to the facility.
Report was made to Law Enforcement on 05/12/25 at 3:30PM Case #25-2841 and Case Manager from VA and Conservator for Client C1 were informed.
Staff interviewed all stated that Special Incident Report (SIR) was sent on 05/12/25 to Licensing and that Case Manager from VA was notified.
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 failed to take action on change of condition, based on interviews conducted and information gathered it was revealed upon observation of Medication Log from the VA dated 04/23/2025
that there was no physician's order for Clonozepam and therefore was not on the Medication list.
MAR's Log also for the month of 05/25 did not have Clonozepam on the list of medications.
Client's C2-C6 all are with the VA and stated the staff does a great job assisting them on VA appointments and transportation and that they have received all doses of their medication and it has always gone smoothly.
Client's C7- C9 said they are assisted with all their medications and it has always gone smoothly.
Stated staff are great and also assist with food service and any other needs they may have.
Staff all stated that Client C1 was admitted on 03/19/25 and had never been prescribed Clonozepam.
All said that Client C1 had not refused taking any medication.
Physician's Report under listed medications does not have Clonozepam listed,
All staff stated that Client C1 never had a change in condition.
It should be noted that Client C1 no longer resides at the facility as of 05/11/25.

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.

Exit interview with Administrator Maria Jacobo conducted and copies of the report provided..


SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2