197606171-12-15-2020-28-AS-MVAO-BXGP8L-20210121100544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 12/15/2020
Date Signed: 12/15/2020 12:48:42 PM

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
10/15/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201015102556

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: 100	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria Jacobo		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Questionable death of resident.

INVESTIGATION FINDINGS:

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Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via tele-video (Facetime) with the facility Administrator Maria Jacobo.
At today's visit Resident # 2 was interviewed at 10:30 AM.
Initial visit was conducted on 10/15/2020 and a Health and Safety Check was conducted.
Tour of the facility was conducted which included the following: 1st floor rooms 1-32 and 2nd floor rooms 33-80, dining room, kitchen, activity room, library, med room, nurses room and 2 outdoor patios.
LPA Trueman conducted interview with the Administrator at 3:15 PM.
Subsequent complaint visit was conducted on 10/22/2020 and Interview was conducted with Administrator on 10/22/2020 at 2:30 PM. Staff 1-3 were interviewed at 2:45 PM to 3:30 PM.
In regards to the allegation Questionable death of resident, information was gathered based on interviews conducted with staff, Resident # 2 and Police report from Montebello Police Department dated 10/03/2020 Report # 20-5990.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

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-20201015102556

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: 12/15/2020

NARRATIVE

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Interview with Resident # 2 revealed that staff was very good and helpful.
Said that staff had acted appropriately.
Staff interviewed stated that Resident # 1 had often taken showers and on 10/03/2020 when Resident # 1 did not come for meds staff went to the room.
Resident # 1 was in her private restroom and staff knocked 4x and called out and when Resident # 1 did not answer staff opened the door Resident # 1 was in the tub with water running and was not responding.
Staff immediately called 911.
Police Report revealed that there was no foul play and that Montebello Police Department Representative spoke to Resident # 1's primary physician will sign the death certificate with diagnosis of Hypertension and Diabetes.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

A telephonic exit interview was conducted with Administrator Maria Jacobo, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

LIC9099 (FAS) - (06/04)

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