197606845-5-19-2023-29-AS-DPEA-CSBU92-20230530152224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:48:30 AM

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
05/27/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220527131255

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:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident fell and sustained a fracture.
Multiple residents were sexually abused 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 a.m. The LPA met with staff and explained the reason for the visit. At 10:12 a.m., the Administrator arrived at the facility.

On 05/27/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility staff neglected R1 resulting in R1 sustaining fractures. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Heidy Bendana.

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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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-20220527131255

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: 05/19/2023

NARRATIVE

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On 05/31/2022, from 09:09am to 1:30pm, Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced 10-day initial complaint visit to the facility. At 9:09am, LPA Peraldi met with facility staff and explained the reason for the visit. At 9:32am, Administrator Cristina Gomez arrived at the facility. At 9:35am, the LPA conducted an interview with the Administrator. The LPA informed the Administrator that the Department received a complaint on 05/27/2022 and a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). The LPA also reviewed records at 9:50am and obtained copies of pertinent documents. Between 11:21am and 11:42am, the LPA along with the Administrator, conducted a physical plant tour. Between 10:46am and 1:12pm the LPA interviewed residents.

On 06/23/2022, Investigator Bendana and Investigator Ryan Miles conducted interviews with R1 and the Administrator. On 07/26/2022, Investigator Bendana conducted interviews with residents and staff; on 08/12/2022 with staff; and on 08/25/2022, with R1’s Primary Care Physician (PCP). Additionally, Investigator Bendana requested and reviewed hospital medical records and facility file documents including Unusual Incident Reports (UIRs) for R1’s falls at the facility.

A review of R1’s physician report, dated 02/14/2022, lists R1’s diagnoses as hypertensive heart disease, Parkinson’s disease, Type 2 Diabetes Mellitus without complication, hypothyroidism, chronic pain, morbid obesity and mild cognitive impairment. The report indicates R1 is able to leave the facility unassisted, able to administer own PRN medications, able to store own medications and is non-ambulatory.

R1’s hospital medical records for hospital admission dates of 10/11/2021, 04/27/2022, and 05/28/2022 were reviewed. R1’s history is listed as Parkinson’s, Neuropathy, Fibromyalgia, Anxiety, Bi-Polar, Hypothyroidism, and Morbidly obese. The chief complaints were listed as chronic pain, right hip pain, and left shoulder pain. X-rays taken on 10/11/2021 of the left hip/pelvis area found no clear evidence of acute fracture or dislocation. Chronic deformity of the right femoral head and shallow acetabulum were noted. Lower lumbar pedicle screws were present. Lower lumbar degenerative disc disease is seen. X-rays taken on 04/27/2022 of the pelvis showed subluxation and deformity of the right hip joint with superior displacement of the femoral head, chronicity is uncertain given the deformity of the femoral head which may be subacute or chronic. Impingement test of the right shoulder was positive. X-rays of the right hip revealed a chronically looking dislocation of the right hip joint with superior migration of the femoral head, dislocation seems to be chronic. X-rays of the left shoulder revealed a presence of degenerative osteoarthritis involving the glenohumeral joint. No evidence of acute fracture or dislocation on the right shoulder. 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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220527131255

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: 05/19/2023

NARRATIVE

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A review of the facility daily assignment sheets documented that staff rounds were completed every 2 hours. The UIRs notated R1 sustained multiple falls at the facility for which aid was administered, paramedics were called, and R1 refused to be taken to the hospital for further medical attention on three (3) different occasions. Per interview with R1, their falls were accidental from tripping or falling asleep in their wheelchair. Per R1, they did not call for staff assistance because they did not need assistance. Information obtained through the course of the investigation found that R1 refused medical attention and refused to call for assistance. The medical records notate R1’s hospital admissions were due to chronic pain in the hip and shoulder with no reports of sustaining fractures. R1 has not sustained any fractures from falls. Therefore, the allegation Neglect/Lack of Supervision: Staff neglected R1 resulting in R1 sustaining fractures is deemed Unsubstantiated at this time.

It was also alleged that multiple residents were sexually abused while in care. It was further reported that Staff #1 (S1) and Staff #2 (S2) were having sexual intercourse with Resident #2 (R2) and Resident # 3 (3). It was also reported that Staff #3 (S3) attempted to have sexual intercourse with R1.

During the initial visit on 05/31/2022 between 9:09 a.m. and 1:30 p.m., the LPA conducted a physical plant tour, reviewed records and obtained copies of documents, interviewed the Administrator and interviewed five (5) residents, including R1 and R2. The LPA conducted a subsequent visit on 04/11/2023 at 9:55 a.m. Between 10:08 a.m. and 11:22 a.m., the LPA conducted a physical plant tour, interviewed the Administrator, and eight (8) out of sixty-four (64) residents. The LPA was informed that R3 passed away approximately three (3) years ago. On 04/11/2023, the LPA also interviewed four (4) staff. On 05/19/2023, between 10:24 a.m. and 10:35 a.m., the LPA interviewed S1, S2 and S3. On 05/19/2023, the LPA attempted to interview R2. Additionally, on 05/19/2023, at 10:53 a.m., the LPA conducted a telephonic interview with R2’s family member.

Interviews conducted revealed that there have not been any issues between staff and residents. Additionally, it was revealed that since February 2021, R1 has had a history accusing male staff and male nurses of inappropriate behavior. The Administrator explained that R1 does not let male staff in R1’s room unless there is a female staff present. The Administrator stated that two (2) staff are present when entering R1’s room to clean or to assist R1. Interviews conducted with multiple residents did not reveal any type of sexual assault/abuse or mistreatment by staff. 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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20220527131255

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: 05/19/2023

NARRATIVE

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Interview with R2’s family member did not reveal any concerns. Staff interviews conducted did not reveal any claims of mistreatment or abuse by any staff. S1, S2 and S3 denied all claims of sexual abuse and mistreatment towards any residents.

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation 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.

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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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