197606171-4-13-2021-28-AS-MVAO-C4AMGE-20210624093550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 04/13/2021
Date Signed: 04/13/2021 01:00:16 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
12/15/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201215095039

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:	04/13/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria Jacobo		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not release resident's records upon request
Facility did not follow reporting requirements

INVESTIGATION FINDINGS:

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The purpose of this report is to deliver the findings from the original complaint dated 12/15/2020.
Initial visit was conducted on 12/23/20 and included the following:
Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with the facility Administrator Maria Jacobo.
At today's visit Staff Maria Jacobo and Robert Blanco were interviewed.
Resident and Staff roster to be submitted.
Facility to submit Admission Agreement, Physician's Report and Emergency ID for Resident # 1.
In regards to the allegation ,Staff did not release resident's records based on interviews conducted and information gathered Staff Maria Jacobo and Robert Blanco and family member of Resident 1 revealed that
files were available to be reviewed. Interviews with staff and family member all revealed that family member was not on record as authorized representative or Power of Attorney and therefore files were not to be released, but could be reviewed..Physician's Report dated 2/10/2020 has the signature of Resident 1.

Unsubstantiated

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: 04/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

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-20201215095039

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: 04/13/2021

NARRATIVE

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Admission Agreement dated 2/24/2020 has the initials of Resident 1 on Page 4 under Notice of Rate Change, on Page 6 under Smoking Policy, Page 7 under Theft and Loss Prevention program, Page 8 under Health Care Directive and also initialed on final page Acknowledgement of Provisions.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

In regards to the allegation, Facility did not follow reporting requirements based on interviews conducted with staff and family member 1 it was confirmed that family member was given the opportunity to review the files, but was not authorized rep or POA and files could not be released.
Facility did appropriate reporting with CCLD upon passing of Resident 1.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Hard copy was submitted to facility for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

LIC9099 (FAS) - (06/04)

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