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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:12:47 PM

Substantiated


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
08/23/2023 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230823145835
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:
08/31/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria JacoboTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff did not ensure the activities calendar was posted
Staff are not providing activities to residents in care
Staff did not ensure the menu was up to date and posted
INVESTIGATION FINDINGS:
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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 08/31/2023 Resident and Staff Roster submitted.
Interviews were conducted with Administrator and Resident's R1-R 6 from 1:10 PM to 2:20 PM.
In regards to the allegation Staff did not ensure the activities calendar was posted, based on interviews conducted and information gathered 6 of 6 residents stated that the activities calendar has not been posted.
Interview with Administrator who confirmed that activities calendar was not posted when Ombudsman had visited the facility on 3 different occasion's.
At today's visit LPA did not observe the Activity calendar posted.
Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations,
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: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 4
Control Number 28-AS-20230823145835
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: 08/31/2023
NARRATIVE
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Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D.
In regards to the allegation Staff are not providing activities to residents in care, based on interviews conducted and information gathered 6 of 6 resident's stated that there are no group activities done by a facility staff member on a daily basis.
All 6 stated that they do no activities other than only Bingo on Tuesday's. Said they just watch television and hang out all day.
Interview with Administrator who stated that they do Bingo and there is not 1 full time staff member responsible for doing activities with the resident's.
Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D.
In regards to the allegation Staff did not ensure the menu was up to date and posted, based on interviews conducted and information gathered, at today's visit LPA saw the menu was posted, but it was dated 08/20 to 08/26 which was for the previous week.
Interviews with 2 of 6 resident's who stated that the menu posted is not accurate.
Interview with Administrator who confirmed that at Ombudsman's visit the menu was outdated and then staff brought current one.
Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations,
Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230823145835
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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
87219(d)
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Planned Activities
In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months.
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Facility to post Activity's calendar and submit by POC due date proof that it is posted.
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This requirement is not met as evidenced by:
Licensee failed to post activities calendar as confirmed by 6 of 6 resident's, observation by LPA and confirmation by administrator which poses an Immediate Health and Safety Concern to resident's in care.
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Type B
09/05/2023
Section Cited
CCR
87219(f)
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Planned Activities
In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.
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Facility to submit to Licensing by POC due date staff member to have full time responsibility of activities and submit verification of 1 year experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.
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This requirement is not as evidenced by:
Licensee failed to have one staff member having full time responsibility to organize, conduct and evaluate planned activities with 6 of 6 resident's stating there are not group activities being done which poses an Immediate Health and Safety Concern to resident's 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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230823145835
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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2023
Section Cited
CCR
87555(b)(6)
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General food Service Requirements
The following food service requirements shall apply:
In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days.
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Administrator to self-certify that all menus posted will be current and submit by POC due date.
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This requirement is not met as evidenced by:
Facility at today's visit had menu posted dated 08/20 to 08/26 which is not the current week which poses an Immediate Health and Safety Concern to resident's 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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4