197606845-6-18-2021-29-AS-JAPL-C4C6ER-20210625204508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 06/18/2021
Date Signed: 06/18/2021 12:17:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2020 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20201203115504

FACILITY NAME:	FINE GOLD MANOR RETIREMENT		FACILITY NUMBER:	197606845
ADMINISTRATOR:	CRISTINA GOMEZ		FACILITY TYPE:	740
ADDRESS:	10537 MAGNOLIA BLVD.		TELEPHONE:	(818) 761-5777
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91601
CAPACITY:	100	CENSUS: 64	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident served an illegal eviction notice.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Salia Walker and Brian Balisi conducted a subsequent complaint visit to address the above noted allegation. During the visit, LPAs Walker and Balisi met with Cristina Gomez at 11:45am and explained the reason for the visit.

On December 10, 2020 at 11:00 a.m., LPA Eva Miller initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, that complaint investigation was conducted virtually with the use of FaceTime with Cristina Gomez, the facility administrator.

The reporting party alleged that resident #1 (R1) was issued an Eviction Notice illegally and/or inappropriately without sufficient cause. The LPA conducted an interview with the administrator between 11:00 a.m. and 11:30 a.m. and requested pertinent documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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 29-AS-20201203115504

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 RETIREMENT	FACILITY NUMBER: 197606845
	VISIT DATE: 06/18/2021

NARRATIVE

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Continued from 9099

After a later review of the documentation, it was observed that the allegation was substantiated as the eviction notice was not valid as written. Although the incidents described in the eviction notice would be valid for the purpose of eviction, no Incident Reports were submitted to Community Care Licensing (CCL). If the incident is serious enough to evict a resident, then it is also reportable to CCL.

In addition, although the Eviction Notice stated that ‘there are several agencies that might help you locate alternate affordable housing’ and to contact you if they would like assistance in identifying those housing, SB 781 requires that the eviction notice actually contains resources to assist the resident in identifying alternative house and care options, including public and private referral services and case management organizations.
On the evening of December 10, 2020 at 7:27 p.m., LPA Miller received a letter rescinding the eviction notice along with a new Appraisal for R1 (LIC 602 Resident Appraisal and a LIC 625 Appraisal/Needs and Services Plan). The administrator further noted a plan that she discussed with R1 to resolve any potential violation of house rules.

Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 809-D).

Exit interview conducted/ Appeal rights provided/ A copy of this report was emailed for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201203115504

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 RETIREMENT	FACILITY NUMBER: 197606845
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/18/2021 Section Cited CCR 87224(d)(B)(1)(2)	1 2 3 4 5 6 7	The licensee shall set forth in the notice to quit the reasons relied upon…Resources available to assist in identifying housing and care options. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator sent notice that the Eviction was rescinded on 12/10/20; therefore, no further plan of correction is required at this time.
	8 9 10 11 12 13 14	Based on interviews and record review, the eviction notice failed to include referral services that will aid in finding alternative housing and a notice of case management organization which help manage individual care and service needs	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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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