197606845-2-22-2023-29-AS-EPEI-CPAU6V-20230222141857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:20:14 PM

Document Has Been Signed on 02/22/2023 02:20 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 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: 60	DATE:	02/22/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	02:30 PM

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	Licensing Program Analyst (LPA) Emily Peraldi conducted a Case Management visit to deliver findings. The LPA met with the Administrator and explained the reason for the visit. On 11/18/2022, the Community Care Licensing Division (CCLD) received a self-reported Unusual Incident/Injury Report (LIC 624) and a Report of Suspected Elder Abuse (SOC341). According to the report, Resident #1 (R1) reported to the facility Administrator that on 11/17/2022 at 9:00pm, Resident #2 (R2) came into R1’s room while R1 was sleeping and touched R1’s breast. R1 kicked R2 and told R2 to leave the room. R2 left the room but shortly thereafter returned to the room to ask R1 to smoke with R2. R1 yelled to R2 to leave the room and R2 left the room. The case was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Peter Zertuche. On 11/21/2022, from 1:34pm to 2:55pm, Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 1:34pm, LPA Peraldi met with the Administrator, Cristina Gomez to follow up on the self-reported incident report received on 11/18/2022. The report pertained to Resident #1 (R1) reporting possible sexual abuse by another resident. At 1:41pm, the LPA conducted an interview with the Administrator. At 1:46pm, the LPA obtained copies of pertinent documents. At 2:00pm, the LPA along with the Administrator conducted a physical plant tour. No immediate health and safety concerns were observed during the visit. The LPA explained that further investigation was required and that a referral was made to the Community Care Licensing Investigation Branch (IB). Investigator Zertuche conducted interviews on 12/06/2022, from approximately 9:30am to 11:30am, with facility Administrator, staff, residents, R1, and R2; and on 12/14/2022, at approximately 2:00pm, with staff. The investigator contacted the Los Angeles Police Department (LAPD) who stated the case was still active with no resolution. In addition, the investigator reviewed facility file documents, including staff and resident rosters, and documents related to R1.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/22/2023

NARRATIVE

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R1 was admitted to the facility on 03/22/2017. According to the physician report, dated 02/24/2022, R1 was listed as non-ambulatory with a diagnosis of hypertensive heart disease and Parkinson’s disease. The staff notes, dated 11/17/2022, indicated R1 was changed at 9:30pm, about 30 minutes after the alleged incident but there were no notes regarding the allegation. Notes also indicated a staff sat outside R1’s room and checked on R1 every 30 minutes during the overnight hours beginning at midnight.

During the interview process, information obtained revealed there were no witnesses to the incident and other residents had good things to say about the facility such as staff checking on them regularly and taking care of issues immediately. R2 denied the allegation with R1 or with other residents. Staff records indicated the staff checked on R1 hourly including a room check 30 minutes prior and 15 minutes after the incident with nothing suspicious documented. There were cameras at the facility, but they do not record. R1 reported the allegation to the Administrator the following morning who immediately contacted the Los Angeles Police Department (LAPD). LAPD has not completed their case and there was no doctor visit for this incident.

Based on the information obtained, the Department does not have sufficient evidence to support the allegation. Therefore, the allegation of “Neglect/Lack of Supervision – Resident #1 (R1) was sexually abused by Resident #2 (R2)” is deemed unsubstantiated at this time.

Exit interview, copy of report given.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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