197606171-12-16-2021-28-AS-MVAO-CB2UQV-20220126144745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 12/16/2021
Date Signed: 12/16/2021 03:14:19 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
12/06/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211206122909

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: 80	DATE:	12/16/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Maria Jacobo		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's sliding door is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 conduct a 10 day complaint visit in regards to the above allegation.
At today's visit the following was done:
On 12/16/2021 at 12:15 P.M. Administrator Maria Jacobo was interviewed.
At 12:30 P.M. Maintenance Staff Fernando Castillo was interviewed.
At 12:40 P.M. to 1:15 P.M. Resident 1 - Resident 3 was interviewed.
At 1:15 P.M. LPA Trueman along with Maintenance Staff Fernando Castillo toured Rooms 1, 2, 3 and 12.
In regards to the allegation Resident's sliding door is in disrepair, during tour LPA observed in Room 1 that the sliding door would not open and the door was not able to move at all through the track on the floor. There also was an open space where air from the outside could come into the room when the door was closed.
In Room 3 the sliding door did not move smoothly though the track on the floor.
Interview was conducted with Client 1 who said the door was hard to close.

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: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20211206122909

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: 12/16/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Maintenance Staff interviewed said that dirt and rain can go into track and make it hard to close the door.
Stated that in Room 1 the door has not been used, but it is not sliding open.
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: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 28-AS-20211206122909

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: 12/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/20/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation 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:	1 2 3 4 5 6 7	Facility to submit proof by POC due date that sliding door in Rooms 1 and 3 are fully operable and in good repair.
	8 9 10 11 12 13 14	Based on observations and interviews the facility failed to have the facility in good repair at all times with Room 1 having a sliding door that was inoperable and didn't slide open which caused an Immediate Health and Safety Risk to residents in care,	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: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3