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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:33:31 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
10/10/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20221010133351
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:
04/11/2023
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Cristina GomezTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident bedroom is filthy, cluttered, and unsuitable.
Resident is not provided clean linens and mattress.
Resident bedroom has insects.
Staff are not assisting resident with activities of daily living.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 10/18/2022, between 2:26 p.m. and 3:20 p.m., LPA Peraldi conducted a facility tour and reviewed records. On 10/18/2022 at 2:31 p.m., LPA Peraldi interviewed the Administrator. During todays visit, at 10:08 a.m., LPA Peraldi, along with the Administrator conducted a physical plant tour. On 04/11/2023, between 10:09 a.m. and 11:15 a.m., LPA Peraldi conducted interviews with eight (8) out of sixty-four (64) residents and four (4) staff. On 04/11/2023, at 11:22 a.m., LPA Peraldi conducted an interview with the Administrator. On 04/11/2023 at 11:20 a.m., LPA Peraldi obtained copies of pertinent documents.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 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)
Page: 1 of 3
Control Number 29-AS-20221010133351
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
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 allegations: Resident bedroom is filthy, cluttered, and unsuitable. Resident is not provided clean linens and mattress. On 10/10/2022, the Department received a complaint alleging that Resident #1 (R1)’s room is filthy, unclean, cluttered, bugs present and missing sheets. During an interview with the Administrator on 10/18/2022, the Administrator stated that R1 does not like when housekeeping staff clean R1’s room, since R1 does not want staff touching R1’s items. However, the Administrator stated that R1 is slowly letting housekeeping staff clean R1’s room. During today’s visit, the Administrator stated that R1 is now comfortable with housekeeping staff cleaning R1’s room. During today’s visit at 10:08 a.m., LPA Peraldi, along with the Administrator conducted a physical plant tour and LPA Peraldi observed nine (9) rooms, including R1’s room. The rooms were observed to be sanitary with clean linens. At 10:19 a.m., LPA Peraldi observed two (2) housekeeping staff cleaning R1’s room and taking out the trash of R1’s room. Throughout todays visit, LPA Peraldi observed housekeeping staff cleaning residents’ rooms and common areas. LPA Peraldi also observed laundry being done at 10:12 a.m. During the interview conducted on 04/11/2023, the Administrator stated that there are two (2) housekeeping staff throughout the week and that each staff are assigned different areas and rooms of the facility to clean. The Administrator stated that during the day from 6:30 a.m. to 3:00 p.m., the housekeeping staff wash residents’ clothes and at night, from 10:00 p.m. to 6:30 a.m., staff wash residents’ bedsheets, covers and blankets. The Administrator stated that when housekeeping staff remove and pick up the dirty bedsheets and linens, the staff replace them with clean sheets and linens. The Administrator stated that residents get their bedsheets changed and cleaned once a week, as well as their personal laundry. Additionally, the Administrator stated that when housekeeping staff clean residents’ room, they take note if a room has an issue or needs special attention. The Administrator provided LPA Peraldi a copy of the washing and cleaning schedule. Resident interviews conducted on 04/11/2023, stated that staff clean resident rooms’ once a week and change their bedsheets once a week as well. The interviews with residents also noted that staff are helpful; no concerns regarding the cleanliness of rooms were brought up during resident interviews. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099-C.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 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)
Page: 2 of 3
Control Number 29-AS-20221010133351
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
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: Resident bedroom has insects. On 10/10/2022, the Department received a complaint alleging that Resident #1 (R1)’s room had bugs. During today’s visit at 10:08 a.m., LPA Peraldi, along with the Administrator conducted a physical plant tour and LPA Peraldi observed nine (9) rooms, including R1’s room. The rooms were observed to be sanitary and LPA Peraldi did not observe bugs or insects in the rooms. The Administrator explained that the facility receives monthly pest control maintenance from a company called Pest Control. The Administrator said if a resident has a bug or insect problem, the Administrator schedules Pest Control to treat the problem. However, the Administrator said there hasn’t been any recent concerns regarding bugs or insects. The Administrator provided LPA Peraldi copies of invoices from Pest Control dating from January 2022 to March 2023. Interviews conducted with residents on 04/11/2023, revealed that residents have not observed bugs or insects in their rooms. 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.

Regarding the allegation: Staff are not assisting resident with activities of daily living (ADL). On 10/10/2022, the Department received a complaint alleging that Resident #1 (R1) was ungroomed, malodorous and disheveled with dirty clothing and dirty nails. Interviews with residents revealed no issues or concerns regarding staff assistance with ADLs. Staff interviews also revealed residents are being assisted with ADLs. 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 HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 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)
Page: 3 of 3