197606171-1-25-2021-28-AS-MVAO-BY3PLW-20210209102525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 01/25/2021
Date Signed: 01/25/2021 11:48:43 AM

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
10/22/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201022100939

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:	01/25/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Jacobo		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Residents' needs are not being met
Lack of supervision resulted in resident to resident disputes

INVESTIGATION FINDINGS:

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The purpose of this report is to deliver the findings from the original complaint dated 10/22/2020.
Visit was conducted on 11/3/2020 and resident's 1-8 were interviewed.
Initial visit was conducted 10/29/2020 and Administrator was interviewed at 2:00 PM.
Staff 1 was interviewed at 2:20 PM.
Staff 3 was interviewed at 2:45 PM.
Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, previous visits were conducted via tele-video (Facetime) with the facility Administrator Maria Jacobo
In regards to the allegation Residents' needs are not being met, interviews with all residents revealed that caregivers will assist with bathing and showering and it has always worked smoothly.
Interviews with residents also revealed that all 3 meals are good quality and residents can also have substitutes.
Interviews with residents also revealed that medication is administered and it has always gone smoothly.
All residents interviewed stated that there meets are being met.

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: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

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-20201022100939

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: 01/25/2021

NARRATIVE

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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.
In regards to the allegation
In regards to the allegation Lack of supervision resulted in resident to resident disputes, based on interviews with all 8 residents they stated there are alot of verbal disputes and staff will always respond very quickly and intervene and calm the situation.
Staff interviewed stated that there are numerous small arguments and they always respond quickly and calm the situation.
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.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
10/22/2020 and conducted by Evaluator Glenn Trueman

COMPLAINT CONTROL NUMBER: 28-AS-20201022100939

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:	01/25/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Jacobo		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility has pests

INVESTIGATION FINDINGS:

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In regards to the allegation Facility has pests, interviews with 2 of 8 resident's revealed that pests were observed within the last 2 weeks.
Mice and roaches were observed.
Interviews with staff revealed that pest control comes weekly to treat for pests. Staff interviewed stated that water bugs have been observed.
Documentation given by the facility reveal weekly visits by pest control.
Based on LPAs observations and interviews which were conducted record review(s), 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.

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

Substantiated

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: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20201022100939

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: 01/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/26/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Facility failed to keep facility clean safe and sanitary with residents stating they observed	1 2 3 4 5 6 7	Documentation provided of weekly visits by pest control. Deficiency cleared
	8 9 10 11 12 13 14	roaches and mice within the last 2 weeks 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: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC9099 (FAS) - (06/04)

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