197606845-4-11-2023-29-AS-DPEA-CRBRUG-20230428131954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:34:45 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
09/29/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20210929141154

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:	04/11/2023
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Cristina Gomez		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff intervened in resident's choice for medical care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 9:55 a.m., the LPA met the Administrator Cristina Gomez and explained the reason for the visit.

During the initial visit on 10/01/2021, between 10:53 a.m. and 11:50 a.m., LPA Peraldi conducted a facility tour and reviewed resident records. On 10/01/2021 between 1:03 p.m. and 2:30 p.m., LPA Peraldi interviewed the Administrator, nine (9) residents and five (5) staff. On 10/06/2021 between 1:30 p.m. and 4:00 p.m., LPA Brian Balisi conducted an unannounced complaint investigation and conducted a physical plant tour, interviewed staff and residents. On 10/06/2021, LPA Balisi reviewed and obtained copies of pertinent documents. Additionally, on 04/10/2023, LPA Peraldi conducted a file review.

Continued on LIC 9099-C.

Unsubstantiated

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: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210929141154

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: 04/11/2023

NARRATIVE

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Regarding the allegation: Staff intervened in resident's choice for medical care. On 09/29/2021, the complainant alleged that staff intervened during Resident #1 (R1) transportation to the hospital on 09/25/2021. On 09/25/2021, R1 called 911 and requested to be transported to Sherman Oaks hospital, the complainant alleges that instead staff at the facility intervened and requested for R1 to be transported to Providence St Joseph in Burbank. Interview with the Administrator conducted on 10/01/2021, revealed that the 911 paramedics transport residents to the nearest hospital that have available beds. The Administrator stated that because of the Coronavirus Disease 2019 (COVID-19) outbreak, that the paramedics were only able to transport the residents to hospitals that have availability. The Administrator denied that the facility staff intervened with R1’s medical care. Additionally, record review conducted by LPA Peraldi on 04/10/2023 of R1’s documents revealed that R1’s Identification and Emergency Information LIC 601 dated 11/27/2020, listed St. Joseph Hospital as the name of hospital to be taken in an emergency. The Administrator stated on 10/06/2021, that the paramedics could have also transported R1 to Providence St. Joseph due R1’s emergency information. Additionally, resident interviews revealed that staff do not intervene on their choice for medical care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

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