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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:49:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/16/2024 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20240916130533
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: 60DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Christina GomezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility failed to provide resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced subsequent complaint visit for the above allegation. LPA arrived to the facility at 11:43 AM met with the facility administrator Christina Gomez entrance interview conducted and the reason for the visit was explained.

During the initial complaint visit on 09/18/2024, the LPA conducted a physical plant, conducted interviews with the Administrator, three (3) staff members, and three (3) residents between 12:52 PM and 02:00 PM. Additionally LPA conducted file review at 02:05 PM, and obtained copies of pertinent documents relevant to the investigation. During today’s visit on 10/16/2024 LPA interviewed the facility administrator and collected documents pertinent to the investigation between 11:43 AM and 12:50 PM.

Continued on LIC-9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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-20240916130533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FINE GOLD MANOR RETIREMENT
FACILITY NUMBER: 197606845
VISIT DATE: 10/16/2024
NARRATIVE
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The allegation of “Facility failed to provide resident's records” alleges that the facility failed to provide Resident #1’s (R1) records to R1’s responsible party (RP). During the initial complaint investigation LPA Byrne obtained copies of the documents that were submitted to R1’s RP. LPA observed that Special Incident Reports (SIRs) were not included in the documents that were submitted. LPA Byrne conducted a review of the facility’s e-file and confirmed that the facility had submitted SIRs to Community Care Licensing for R1 previously. During the subsequent complaint investigation conducted on 10/16/2024 LPA Byrne interviewed S1 and asked if they had SIRs for R1. S1 confirmed that they had the documents and provided copies to the LPA. LPA Byrne asked S1 why these documents were not submitted along with the rest of R1’s file. S1 stated that the SIRs are stored in a separate binder from the rest of the resident’s files, and they don’t know if the SIRs were submitted as that is handled by the main office. LPA confirmed with RP that no SIRs were submitted alongside R1’s file. Based on the information obtained during the interview and record review there is sufficient evidence to support the allegation that the facility failed to provide resident's records. Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240916130533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINE GOLD MANOR RETIREMENT
FACILITY NUMBER: 197606845
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
87506(c)(1)
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87506 Resident Records
(c) All... records...regarding residents shall be confidential.
(1)...The licensee...shall reveal or make available... upon the resident's written consent or that of his designated representative.
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Administrator will submit a statement of understanding confirming that they have read the entirety of CCR 87506 and that they understand that SIRs are part of the resident's files. Administrator will submit the document to CCL no later than the POC due date.
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This requirement is not met as evidenced by: Based on interview and record review, the licensee failed to comply with the section cited above as SIRs for R1 were not submitted to R1's responsible party which poses a potential personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3