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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 07/13/2020
Date Signed: 07/13/2020 01:14:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FINE GOLD MANOR RETIREMENTFACILITY NUMBER:
197606845
ADMINISTRATOR:CRISTINA GOMEZFACILITY TYPE:
740
ADDRESS:10537 MAGNOLIA BLVD.TELEPHONE:
(818) 761-5777
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91601
CAPACITY:100CENSUS: 65DATE:
07/13/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cristina GomezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Brian Balisi initiated a case management visit for the self reported incident, which occurred on 7/9/2020. On 7/10/2020 Licensing received information that Resident 1 (R1) informed Administrator that Resident 2 (R2) allegedly inappropriately touched R1 approx 2 weeks prior to 7/8/2020.R1 also informed administrator that Resident 3 (R3) stated to R1 that R2 used to inappropriately touch R3 for some time.

Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management was conducted telephonically at 12:30pm with Cristina Gomez, the facility administrator.

Between 10:30am - 11pm LPA conducted telephone interviews with the administrator and a video call which consisted of a review of physical plant. LPA also requested copies of Census, Staff schedule, admission agreement and resident documentation relevant to the incident, to be emailed to the LPA by end of business day today.

LPA interview with administrator revealed that R2 was moved to a room on the first floor. R1 and R3 are okay with the move and still feel safe and secure with R2 being in the facility.

Further review required prior to LPA concluding the investigation telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature. 
SUPERVISOR'S NAME: Alex EstradaTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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