197606171-9-21-2023-28-AS-RORN-CW2UJR-20230926153757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:43:56 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
12/22/2021 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211222080952

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:	09/21/2023
		ANNOUNCED	TIME BEGAN:	10:34 AM
MET WITH:	Maria Jacobo - Administrator		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Resident sustained bruising at the facility.
Facility is not maintained clean.
Residents are not fed nutritious foods at the facility.
Residents do not have access to healthcare while at the facility.
Facility house-keeping staff is bathing residents at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera made an unannounced subsequent visit to the facility and met Administrator Maria Jacobo, the purpose for todays visit was explained.

The investigation consisted of the following:
On 12/23/21 LPA Glenn Truman conducted the initial 10 day visit and interviewed Resident's 1-6 and Staff 1-2, toured dining room, observed dinner meal being served and obtained copies of Resident and Staff Rosters.

LPA Tena Herrera conducted a subsequent on 9/21/23, obtained a copy of the Staff/Resident rosters, copies of the 4 rotating food menus, toured the facility with Administrator Maria Jacobo, observed lunch being served for day, interviewed 6 Staff and 8 residents, and obtained copies of staff trained to assist residents with Activities of Daily Living.
(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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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-20211222080952

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: 09/21/2023

NARRATIVE

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The investigation revealed the following:
Allegation: Resident sustained bruising at the facility.
It is alleged that residents at the facility have complained about physical abuse and there are claims of having photos to prove alleged abuse. LPA’s Herrera and Truman conducted a total of 13 interviews combined and 12 out of 13 residents deny the above allegation and state that they have never been abused or bruised by staff. Resident 1 (R1) provided photos of bruising to LPA Herrera although the photos do contain bruising on ankle, hand, and other unknown areas, it could not be determined that the bruising was caused by staff as there were no other witnesses or video footage of incident. Interviews with staff present during alleged abuse incident (Staff 1, 3 and 4) denied causing injury or bruising to R1 and state they were unaware of any bruising and do not know how resident sustained bruises and/or injuries. LPA observed police report provided by R1, however, report does not indicate bruising or supportive evidence that the officers observed the alleged injuries.
Allegation: Facility is not maintained clean.
It is alleged that the facility is visibly filthy. LPA toured both floors of facility during todays visit including common areas, kitchen and 5 resident rooms. Facility appeared to be clean and sanitary, beds were made, floors in rooms were clean and trash within rooms were empty. LPA observed house keepers cleaning and moping resident rooms during tour. 12 out of 13 residents interviewed denied the above allegation, stated that the facility is cleaned daily, rooms get a deep cleaning weekly, housekeepers make beds and take out residents trash within rooms daily. 6 out of 6 staff interviewed denied the above allegation and stated that the facility is cleaned regularly during each shift and as needed, deep cleaning in residents rooms are scheduled for once weekly, however, housekeeping makes beds and takes out residents trash within their rooms daily.
Allegation: Residents are not fed nutritious foods at the facility.
It is alleged that the facility provides a poor nourishment to the residents in care. LPA toured kitchen and meal served during lunch hour, the kitchen had proper food supply to meet regulations. Meal was observed to be of proper nutrition and included fruit, vegetable, meat and bread, alternate lunch was also observed. LPA reviewed monthly menu, facility has 4 different month menus that are rotated.
(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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211222080952

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: 09/21/2023

NARRATIVE

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11 out of 13 residents interviewed denied the above allegation and state that the food served is of proper nutrition and satisfying. 6 out of 6 staff interviewed stated that the facility follows menu schedule, they offer alternative menu options and meals are of proper nutrition.
Allegation: Residents do not have access to healthcare while at the facility.
It is alleged that the facility provides residents with a lack of proper access to health care. No additional information was provided. 6 out of 6 Staff interviews revealed that some residents are independent and prefer to handle their own medical needs, however, there is an in house primary physician and psychiatric doctor who visit with residents on a monthly basis, this option is offered upon admission and the facility provides transportation for residents who need to see doctors outside of the facility. 12 out of 13 residents deny the above allegation and state that the facility provides access to in house visits with the facilities primary doctor and/or psychiatric doctor monthly, those who are independent and handle their own medical appointments stated that the facility provides them with the transportation needed to visit with their doctor.
Allegation: Facility house-keeping staff is bathing residents at the facility.
It is alleged that the facility house-keeping staff is assisting with bathing residents. No additional information was provided. 6 out of 6 interviews with staff revealed that all staff are trained in assisting with residents activities of daily living (ADL’s) which include bathing, incontinence care and grooming. LPA reviewed training logs for staff and observed staff listed as “house-keeping” and "kitchen staff" have received the proper training to assist residents with ADL’s. Of the 8 interviews conducted during todays visit only 1 resident requires assistance with bathing and stated that a caregiver is who assists with their bathing and grooming.

Based on statements and interviews conducted with staff/clients, review of training records and LPA observations, 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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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