197606171-10-30-2023-28-AS-TVAO-CXBR3N-20231106114015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:44:21 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
06/29/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210629134833

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: 72	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Administrator, Maria Jacobo		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff did not maintain a safe environment for residents.
Facility is not in good repair.
Facility has bedbugs.
Facility does not provide meals and snacks for diabetic diet.
Facility does not provide adequate food service.
Resident is not receiving mail.
Resident did not get 60-day notice of rent increase.
Facility does not provide activities.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegations listed above. LPA met with Administrator, Maria Jacobo, and explained the purpose of the visit.

On 7/8/21, LPA Glenn Trueman conducted the initial visit and interviewed the administrator and a resident. On 10/30/23, LPA Chan toured the facility and randomly selected 8 rooms (rooms #4, #11, #23, #26, #36, #44, #51, and #68) to inspect. Interviews were held with the administrator, 5 Staff, and 8 Residents. LPA also reviewed 5 resident files.

The investigation revealed the following:
1. Allegation - Staff did not maintain a safe environment for residents. It was alleged that the staff allow people to smoke inside their rooms, allow to sell marijuana, and have registered sex offenders at the facility. LPA interviewed administrator, staff, and residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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-20210629134833

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: 10/30/2023

NARRATIVE

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The administrator stated the residents could smoke outside in the patios or outdoors but not in their rooms. She had not heard of any residents selling marijuana in the facility nor do they hire staff or admit residents who are registered sex offenders. Staff stated they do not allow residents to smoke in their rooms. They have not witnessed any residents selling marijuana or other drugs either. 7 out of the 8 residents interviewed stated the residents do not smoke in their rooms. They go outside to the patio where it is allowed. They have not seen or heard of any residents selling marijuana at the facility. They stated they feel safe residing here.

2. Allegation - Facility is not in good repair. It was alleged that the air conditioner was not working for almost 2 years, the elevators are frequently breaking down, and the ceiling had leaks. Per the administrator and staff, when things are not working properly, the maintenance personnel will try to fix it immediately. She stated the facility is an older building and they are maintaining the physical plant as best as they could. When the elevator is in disrepair, she contacts the outside elevator technician and they come right away to repair it. During the tour today, LPA observed the elevator and air conditioners working properly. The rooms inspected did not have any water leaks from ceiling. 3 out of 8 residents stated the elevator breaks down at time but they will fix it right away. One reported the elevator has been down for 10 months. The rest did not have any issues with things in disrepair.

3. Allegation - Facility has bedbugs. Administrator and staff stated they have not seen or received any reports of bedbugs from residents. LPA obtained the pest control report which was last serviced on 6/6/23. Per administrator, the maintenance staff has been performing the pest inspections and spraying the facility. Staff stated the maintenance person conducts random room checks every week to observe for pests. 7 out of the 8 residents interviewed had not seen any bedbugs in their rooms. During the visit today, LPA inspected 8 rooms and found a dead bed bug with blood stain in room #36. Although a bed bug was discovered, the facility does not have an infestation of pests nor has not been neglectful. The maintenance staff has been inspecting rooms weekly to ensure there are no bugs.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20210629134833

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: 10/30/2023

NARRATIVE

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4. Allegation - Facility does not provide meals and snacks for diabetic diet. Administrator and staff stated their meal plans are created and meets the dietary needs of the residents. The foods are cooked with minimal salt and offer sugar-free desserts. LPA also interviewed the dietitian via telephone, who stated a visit is conducted monthly to ensure there is adequate food supplies, cleanliness of the kitchen, and the menu is appropriate for residents’ diets. At the visit today, LPA observed serving of foods that meet the different food groups. They had rice, chicken, soup, vegetables, and jello. 7 out of 8 residents stated the facility serves foods that are appropriate for those who are diabetics or have dietary restrictions. One stated he/she cooks own food and does not eat the food served at the facility.

5. Allegation - Facility does not provide adequate food service. It was alleged the facility rarely serve the foods reflected on the menu. Per administrator, the cook will replace an item in the menu if it is not available that day and stated it does not occur often. The cook stated the menu is generated ahead of time and they will ensure there is sufficient items. Cook will also follow the menu and cook with less salt/sugar. They also have alternatives if residents do not want the main course. 6 out of the 8 residents interviewed stated the facility serve the foods according to the menu.

6. Allegation - Resident is not receiving mail. Administrator stated mails are received usually in the mornings and are distributed to the residents while they are having lunch or are brought to the resident rooms. Staff stated they are sometimes asked to deliver their mails and do not open their mails. LPA interviewed 8 residents, and all stated they receive their mails unopened.

7. Allegation - Resident did not get 60-day notice of rent increase. The administrator stated the rent increases as the Social Security office increases the SSI amount. A notice is provided to the person who pays the rent, which is either the resident or family member. The letter is given ahead of time and when the facility receives notification of increase for SSI recipients only. LPA reviewed 5 resident files and observed they have signed admission agreement acknowledging the increased rates. One resident refused to accept the rent increase and did not sign form. 3 of the 8 residents interviewed stated they will receive notification before the rent increases, while one indicated the facility did not provide notice. The rest of the residents either have not had an increase of rent at the moment or someone else pays their rent.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20210629134833

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: 10/30/2023

NARRATIVE

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8. Allegation - Facility does not provide activities. LPA toured the facility and observed an activity calendar. There are board games and books available for residents to use. The ping pong table is available when requested. Administrator and staff stated they provide activities to residents daily. The residents interviewed stated there are some types of activities provided daily, but some do not wish to participate. They also have board games, coloring, and books available.

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.

An exit interview was conducted with administrator Jacobo. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

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