197606171-11-23-2021-28-AS-MVAO-CBGVP9-20220209153624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606171
Report Date: 11/23/2021
Date Signed: 11/23/2021 03:12:40 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
10/08/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211008094807

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: 79	DATE:	11/23/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Staff Carmen Virrueta		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident is being illegally evicted from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff Carmen Virrueta and explained the reason for the visit.
The purpose of the visit is a subsequent visit and to deliver findings in regards to the above allegation.
The initial visit was conducted on 10/12/2021 and the following was done:
At 9:45 A.M. Staff Robert Blanco was interviewed. At 10:00 A.M. Resident 1 was interviewed. At 10:30 A.M. Administrator Maria Jacobo was interviewed. At 10:50 A.M. Maintenance Staff Fernando Castillo was interviewed.
At today's visit 11/23/2021 Resident 2 was interviewed at 1:45 P.M.
In regards to the allegation Resident is being illegally evicted from the facility, based on interviews conducted with staff and residents and documents reviewed from the file of Resident 1 it was revealed by Resident 1 that her family member did come into the facility office and grab a key and throw it at the Administrator.
Special Incident Report (SIR) dated 8/17/2021 was submitted by the facility stating that family member of Resident 1 threw office keys at the Administrator and 911 was called. Police were called .

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: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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-20211008094807

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: 11/23/2021

NARRATIVE

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Staff interviewed stated that family member of Resident 1 had cursed out another resident recently and wanted to fight that resident.
Resident 2 stated that family member of Resident 1 had cursed at him and spit on him.
Staff said family member would fight with Resident 1 and curse at her.
LPA witnessed a video of family member pushing Resident 1 in front of the facility.
Admission Agreement dated 06/27/2019 under Eviction procedures states that upon 30 day written notice in writing can evict for failure of resident to comply with general policies of the facility. Said general policies must be in writing.
In Admissions Agreement under House Rules it states that no resident may have family/visitors that are abusive to other residents/staff nor upset the general facility population.
Title 22 Regulations 87224(a) states the following:
The licensee may evict a resident for one or more of the reasons listed in section 87224 (a)(1) thru (5).
Notated in (3)- Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.

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: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

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