197606845-6-9-2022-29-AS-KHEN-CFTVTV-20220628164344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 06/09/2022
Date Signed: 06/09/2022 06:46:18 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
10/19/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20211019153612

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:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	10:34 AM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	06:57 PM

ALLEGATION(S):

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Resident was not provided medical attention in a timely manner.
Resident sustained fractures while in care.

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., the LPA met with Administrator, Cristina Gomez and explained the reason for the visit.

On 10/19/2021, the Department received a complaint regarding Resident #1 (R1) sustaining fractures while in care and failure to seek medical attention in a timely manner. On 10/17/2021, R1 was transported and admitted to the hospital because of a fall. R1 suffered from muscle Rhabdomyolysis, which is defined as a breakdown of muscle tissue that releases damaging protein into the blood. It was reported that staff found R1 within 30 minutes of the fall. However, the amount of muscle loss R1 suffered would have taken more than 30 minutes to achieve. On 10/19/2021, the complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Seng.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 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 4

Control Number 29-AS-20211019153612

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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On 10/20/2021, from 7:02 a.m. to 9:10 a.m., Licensing Program Analyst (LPA) Emily Peraldi conducted the initial complaint visit. During the visit, LPA Peraldi conducted a physical plant tour between 7:20 a.m. and 7:33 a.m. Additionally, LPA Peraldi interviewed residents from 7:22 a.m. to 7:41 a.m. LPA Peraldi also reviewed records at 8:00 a.m. and obtained copies of pertinent documents. No immediate health and safety concerns were noted. LPA Peraldi determined further investigation was required.

According to the medical records, R1 was transported via ambulance to the Saint Joseph Medical Center on 10/17/2021, at 5:54 p.m., for the evaluation of “left lower back pain” due to a fall. It was reported that R1 had no trauma when brought to the hospital, however, trauma to the knees, elbows and abdomen were found on arrival. R1 was diagnosed with the following: Acute Kidney Failure with Tubular Hecrosis, Metabolic Encephalopathy, Multiple Fractures of ribs, right side, initial encounter for closed fracture, Cellulitis Unspecified, Essential (Primary) Hypertension, Personal History of Nicotine Dependence, Other Specified Abnormalities of Plasma Proteins, Other Abnormalities of Gait Mobility, Traumatic Ischemia of Muscle, Initial Encounter, Hemorrhage, Not Elsewhere Classified, Contusion of Unspecified Knee, Initial Encounter, Contusion of Lower Leg Initial Encounter, Non-Pressure Chronic Ulcer of Skin of Other Sites With Unspecified Severity. According to the medical records and interviews with medical professionals, it was determined the amount of muscle loss suffered by R1 does not match the severity of R1’s fall.

On 12/02/2021, Investigator Dennis Seng conducted an interview with the Reporting Party (RP). On 11/10/2021, medical records were requested. On 01/03/2022, medical records were received and reviewed. On 12/23/2021, Investigator Seng conducted interviews with four (4) staff, including the facility Administrator. On 12/23/2021, Investigator Seng conducted interviews with five (5) residents, including R1. Resident interviews revealed that staff did not check on the residents daily before R1’s fall. However, after R1’s fall, the staff began to conduct daily wellness checks on all residents. Staff interviews also confirmed that staff did not conduct daily wellness checks on the residents until after R1’s fall. Staff interviews also noted that R1 was independent and preferred to be alone. Resident interviews also confirmed that R1 was very independent, and noted that R1 would drive a personal vehicle. Interview with R1 revealed that staff did not check on R1 for months at a time prior to the fall, but after the fall, staff would conduct daily wellness checks.

Continued on LIC 9099-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 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)

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Control Number 29-AS-20211019153612

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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Based on the information obtained, the Department does have sufficient evidence to support the above allegations. Therefore, the above allegations are 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 with Administrator. Appeal rights provided. A copy of this report and appeal rights will be emailed.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 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: 3 of 4

Control Number 29-AS-20211019153612

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 A 06/10/2022 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312(a)Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agreed to do the following: Submit a Plan of Action, documenting how the facility will provide proper level of care and supervision to ensure all residents needs are met. Submit plan by 06/10/2022.
	8 9 10 11 12 13 14	Based on the investigation, interview and record review, the licensee did not comply with the section cited above as the Licensee failed to provide adequate care and supervision to R1 which attributed to R1 sustaining fractures while in care which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type A 06/10/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 (a)(1)Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility.1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions&needs of residents.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agreed to do the following: Submit plan of action to arrange for medical care in a timely manner when necessary to ensure resident needs are met. Submit to CCL by 06/10/2022.
	8 9 10 11 12 13 14	Based on the investigation, interview and record review, the licensee did not comply with the section cited above as the Licensee failed to seek medical attention in a timely manner to R1 which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 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)

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