197606171-8-25-2021-28-AS-WSHO-C74MTR-20210922095354

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:02:58 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
08/18/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210818111726

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: 86	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Maria Jacobo		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility has bed bugs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Maria Jacobo and explained the reason for the visit.
The purpose of the visit is to deliver findings from the original complaint dated 8/18/2021.
The initial visit was conducted on 8/19/2021 and the following was done:
LPA Trueman conducted interviews with the Licensee ,Administrator, Staff S 1-3 and Resident's R 1-8 from 12:45 PM to 2:00 PM.
LPA along with Maintenance Staff toured the facility and inspected Rooms 14, 22, 25, 28, 30, 31,34 A, 37, 46, and 74.
In regards to the allegation facility has bed bugs, based on interviews conducted and information gathered all clients interviewed stated that there have been no bed bugs that they have seen in their room or in the facility.
Staff interviewed stated that there has been no bed bugs. Maintenance staff stated they have turned over mattresses and washed bedspreads and have not seen any bed bugs.
Facility submitted Pest Control Documentation from visits to the facility 7/23,7/30, 08/06 and 08/13.

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: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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-20210818111726

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: 08/25/2021

NARRATIVE

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LPA along with Maintenance Staff toured the facility on 8/19/2021 and inspected Rooms 14, 22, 25, 28, 30, 31,34 A, 37, 46, and 74.. Upon inspection there were no bed bugs observed in the rooms toured.

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.
Exit interview conducted and copy to be provided via e-mail.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

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