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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 06/09/2022
Date Signed: 06/09/2022 06:41:04 PM

Unsubstantiated


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
12/02/2020 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20201202114533
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: 64DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Cristina Gomez, Administrator TIME COMPLETED:
06:55 PM
ALLEGATION(S):
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Failure to accord residents with dignity in their personal relationships with staff.
Failure to allow residents to leave or depart the facility and/or rooms.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver findings for the above allegations. At 10:34 a.m., LPA Peraldi met with Administrator, Cristina Gomez and explained the reason for the visit.

On 12/10/2020, from 10:30 a.m. to 11:00 a.m., Licensing Program Analyst (LPA) Eva Miller conducted the initial 10-day complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with the use of "FaceTime" with Administrator, Cristina Gomez. During the virtual visit, LPA Miller conducted an interview with the facility Administrator and requested pertinent documents.
On 06/09/2022, between 11:17 a.m. and 11:30 a.m., LPA Peraldi and the Administrator toured the facility. At 10:39 a.m., LPA Peraldi conducted an interview with the Administrator. At 10:55 a.m., LPA Peraldi reviewed records and obtained copies of pertinent documents. Between 1:52 p.m. and 3:05 p.m., LPA Peraldi conducted interviews with seven (7) out of sixty-four (64) residents and four (4) staff.Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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 5
Control Number 29-AS-20201202114533
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: 06/09/2022
NARRATIVE
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Regarding the allegation: Failure to accord residents with dignity in their personal relationships with staff. It was alleged that facility staff were observed yelling at and using profanity towards facility resident(s). Interview conducted with Administrator on 12/10/2020, noted that no staff were reported yelling at residents. Interviews conducted with seven (7) out of sixty- four (64) residents on 06/09/2022, revealed that residents believe that facility staff are nice and helpful. The interviews with residents also noted that staff are patient. Interviews conducted with four (4) staff on 06/09/2022, claim that facility staff do not yell at residents. Based on the information obtained, there is insufficient evidence to support the claim that facility staff failed to accord residents with dignity in their personal relationships with staff. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Failure to allow residents to leave or depart the facility and/or rooms. It was alleged that facility residents were prohibited from leaving the facility or the rooms. During the time of the allegation, of December 2020, the facility had a COVID- 19 outbreak from the dates: 11/28/2020 through 12/29/2020. Interviews conducted with Administrator on 12/10/2020 and on 06/09/2022, claimed that facility staff were encouraging, not forcing, residents to stay inside and limit the time spent at the common areas of the facility. The interview also stated that facility staff were reminding residents of the Public Health guidelines at the time. Guidelines issued by the Department of Social Services through the Provider Information Notice (PIN) 20-43-ASC-CCR, dated December 1, 2020 recommended the following but not limited to: Consider the number and rate of COVID-19 and plan accordingly, indoor gatherings strongly discouraged in Red, Orange and Yellow Tiers, gatherings limited to two hours or less.

Interviews conducted with seven (7) out of sixty- four (64) residents on 06/09/2022, revealed that majority of the residents do not recall or remember the specific procedures that the facility took during the COVID-19 pandemic and what the facility was encouraging. One (1) out of seven (7) residents interviewed on 06/09/2022, does recall being in quarantine twice throughout the COVID-19 pandemic, but noted that the quarantines were necessary to keep everyone safe. Interview with Resident #1 (R1), on 06/09/2022, revealed that R1 was afraid to leave R1’s room and R1 believes that the Administrator handled the COVID-19 outbreaks well and that the Administrator “saved many lives.” Based on the information obtained, there is insufficient evidence to support the claim that facility prohibited residents from leaving the facility or the rooms This allegation is deemed Unsubstantiated at this time.
Exit interview conducted and report reviewed with the Administrator. A copy of reports and appeal rights will be emailed.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/02/2020 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20201202114533

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: 64DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Cristina Gomez, Administrator TIME COMPLETED:
06:55 PM
ALLEGATION(S):
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9
Failure to keep passageways free from obstruction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver findings for the above allegation. At 10:34 a.m., LPA Peraldi met with Administrator, Cristina Gomez and explained the reason for the visit.

On 12/10/2020, from 10:30 a.m. to 11:00 a.m., Licensing Program Analyst (LPA) Eva Miller conducted the initial 10-day complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with the use of "FaceTime" with Administrator, Cristina Gomez. During the visit, LPA Miller conducted an interview with the facility Administrator and requested pertinent documents.
On 06/09/2022, between 11:17 a.m. and 11:30 a.m., LPA Peraldi and the Administrator toured the facility. At 10:39 a.m., LPA Peraldi conducted an interview with the Administrator. At 10:55 a.m., LPA Peraldi reviewed records and obtained copies of pertinent documents. Between 1:52 p.m. and 3:05 p.m., LPA Peraldi conducted interviews with seven (7) out of sixty-four (64) residents and four (4) staff.Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20201202114533
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: 06/09/2022
NARRATIVE
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Regarding the allegation: Failure to keep passageways free from obstruction. It was alleged that facility staff had secured the main front door with the use of broomsticks (or similar) to prevent entrance and/or exits. Interview conducted with Administrator on both 12/10/2020 and 06/09/2022 revealed that the stick at the main entry door was placed there at night to prevent anyone from entering the building. The stick was put in place because the lock for the front main door was broken. The interview also revealed that the Fire Department told the facility to remove the stick, regardless of how easily the stick can be removed, it was still an obstruction. The Administrator does not recall the date and time that the Fire Department went to the facility, but remembers it was around December 2020. Interview with Administrator and staff on 12/10/2020 and on 06/09/2022, revealed that maintenance staff fixed the main front door immediately and removed the stick.

Based on the information obtained, there is sufficient evidence to support the claim, that passageways were not kept free of obstruction. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and report reviewed with the Administrator. A copy of reports and appeal rights will be emailed.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20201202114533
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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2022
Section Cited
CCR
87307(d)(6)
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87307(d)(6) Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction
This requirement is not met as evidenced by:
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The Licensee agreed to:
Ensure all passageways are kept free from obstruction. Conduct an in-house training with staff on Regulation 87307 and submit to CCL by 06/23/2022.
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Based on interviews, the Licensee did not comply with the section cited above as the facility placed a stick at the main entry door which posed a potential health and safety risk to residents in care.
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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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5