197606171-10-3-2024-28-AS-RORN-DA4SJB-20241016135452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:53:53 AM

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
09/26/2024 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240926144908

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: 78	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maria Jacobo		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff at facility failed to properly store medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff Robert Blanco 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 allegation.
At today's visit the following was done:
On 10/03/2024 Resident and Staff Roster submitted.
Interviews were conducted with the Administrator and Staff S1 and Resident's R2, R3, R5 and R6..
Resident R1 and R4 were unable to be interviewed because of being hospitalized.
File for Resident R1 was reviewed and Admissions Agreement and Physician's Report were submitted.
LPA conducted a tour along with Staff S1 which included Rooms 3, 12, 13, 14, 17 and 27.
LPA reviewed doctor's orders for Resident R2- R6.
In regards to the allegation Staff at facility failed to properly store medication, based on interviews conducted and information gathered it was revealed by the Administrator and Staff S1 that they were informed during a tour of Resident R1's room by a Veteran Affairs (VA) Representative that there was an inhaler in the room of

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240926144908

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: 10/03/2024

NARRATIVE

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Resident R1..Both staff confirmed that the inhaler was in Resident R1's room and that a doctor's order was needed and Resident R1 did not have a doctor's order.
Interview with VA Representative stated that inhaler was found in Resident R1's room and that there was not a doctor's order allowing it to be in the room.
Physician's Report for Resident R1 dated 08/19/24 listed under Medication Management, ls able to administer own Prescription Medications it states no.
Also listed for Resident R1 under able to administer own PRN medications it states no.
Interviews were conducted with Resident's R2, R3, and R6 who all stated taht they use the inhaler and they take on their own and have had no issues. All 3 had a doctor's note for the inhaler to be in their room.
Resident R5 also had a doctor's note for Tylenol and stated it has gone smoothly.
Resident R1 and R4 are both hospitalized. There was a doctor's order for Resident R4 to have an inhaler in their bedroom.

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240926144908

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: 10/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/03/2024 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.	1 2 3 4 5 6 7	Facility to submit by POC due date training regarding medication management and submit signed log of who had attended. Administrator at visit submitted a Training Log pertaining to medication management that was conducted on 10/02/24. Deficiency cleared.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Licensee failed to ensure that medication was kept in a safe and locked space with inhaler observed in R1's room which posed an Immediate Health and Safety concern.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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