<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 06/09/2022
Date Signed: 06/09/2022 06:50:58 PM

Substantiated


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
06/09/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20220609085705
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:
06:58 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility incorrectly charging resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced 10-day initial complaint visit at the facility today. At 10:34 a.m., the LPA met with the Administrator, Cristina Gomez and explained the reason for the visit.

At 10:39 a.m., LPA Peraldi conducted an interview with the Administrator. At 11:17 a.m., the LPA and the Administrator toured the facility. The LPA also reviewed records at 10:55 a.m. and obtained copies of pertinent documents. Between 1:52 p.m. and 3:05 p.m., LPA Peraldi interviewed seven (7) 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: 1 of 3
Control Number 29-AS-20220609085705
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
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
Regarding the allegation: Facility incorrectly charging resident. It is being alleged that the facility is overcharging Resident #1 (R1) for rent. Per record review and interviews, as of 01/01/2022, R1 is being charged $1231.77. On 11/19/2021, the Department of Social Services, Community Care Licensing Division released the Provider Information Notice (PIN) 21-23-CCLD, which describes the estimated SSI rate increase (Described as PIN 21-23-CCLD ESTIMATED SSI/SSP PAYMENT STANDARDS EFFECTIVE JANUARY 1, 2022). The amount payable for basic services was listed as $1,211.77. The bottom of the PIN is as follows: Recipients who have income in addition to their SSI/SSP check (for example, a pension, Social Security retirement, or disability benefits) can be charged the $1,211.77 amount for basic services plus an additional $20. Because federal rules do not count the first $20 of a recipient's income against his/her SSI/SSP grant, an SSI/SSP recipient with other income has an extra $20 that people who receive only an SSI/SSP check do not have. Neither federal nor state law restricts the recipient in how this additional $20 amount is spent. Thus, if the recipient agrees in the admission agreement to pay the additional $20 for basic services, the facility may charge the additional amount.

Per record reviews and interviews, R1 does not receive income in addition to the SSI/SSP check, which should not allow the facility to charge an additional $20. Interview with the Administrator revealed that R1 did not let the facility know about R1’s income when the Administrator discussed with R1 the specifics of the increase. Based on the information obtained, there is sufficient evidence to support the claim, that the facility is overcharging R1 on rent. 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 Administrator. A copy of the report and appeal rights waill be provided via email.
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 3
Control Number 29-AS-20220609085705
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)
Request Denied
Type B
06/23/2022
Section Cited
CCR
87464(e)
1
2
3
4
5
6
7
87464 (e) Basic Services (e) If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to do the following:
Review R1’s income and correct the overcharge. Amend R1’s admission agreement to include the correct amount. of Submit proof to CCL by 06/23/2022.

8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above as the Licensee failed to correctly charge R1 for rent which posed a potential 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: 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: 3 of 3