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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 11/21/2022
Date Signed: 11/21/2022 02:45:33 PM


Document Has Been Signed on 11/21/2022 02:45 PM - It Cannot Be Edited

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:
11/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Cristina Gomez, AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 1:34 p.m., the LPA met with Administrator, Cristina Gomez and explained the reason for the visit.

The reason for today's inspection is to follow up on a self-reported incident report received on 11/18/2022. The report pertains to Resident #1 (R1) reporting possible sexual abuse by another resident. At 1:41 p.m., the LPA conducted an interview with the Administrator. At 1:46 p.m., the LPA obtained copies of pertinent documents. At 2:00 p.m., the LPA along with the Administrator conducted a physical plant tour.

No immediate health and safety concerns were observed during today's inspection.

Further investigation is required at this time. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). Additional report may follow if warranted.

Exit interview conducted and report reviewed with the Administrator. A copy of the report will be emailed.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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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