197606845-6-9-2023-29-AS-DPEA-CU4PSU-20230726113452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 06/09/2023
Date Signed: 06/09/2023 10:26:01 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
11/02/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20211102124056

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: 67	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cristina Gomez		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident did not have access to drinking water

Resident was locked in the room

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver findings for a complaint initiated by LPA Emily Peraldi on 11/03/2021. At approximately 9:30am,LPA met with staff and explained the reason for the visit. Administrator Cristina Gomez arrived shortly after.

On 11/02/2021, the Department received a complaint alleging Resident #1 (R1) had been locked in R1’s room for days and did not have access to drinking water.

During the initial visit on 11/03/2021, between 10:06 a.m. and 12:50 p.m., LPA Peraldi conducted a facility tour, interviewed seven (7) staff, eight (8) residents including R1 and the Administrator. At 10:13 a.m., LPA Peraldi also reviewed records and obtained copies of pertinent documents.
Per R1’s Physicians Report dated 04/27/2021, R1 does not require any assistance with Activities of Daily Living (ADL) from facility staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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-20211102124056

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: 06/09/2023

NARRATIVE

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Continued from 9099

Interviews conducted and documents reviewed reflected that R1 sustained a fall in October 2021; however, R1 was not able to recall how long R1 was unable to walk for. Per interview with R1, R1 can leave the room without assistance though, due to the fall R1 was unable to walk. R1 further stated that during the time of the fall, R1 crawled around R1’s room to eat food and drink water and never called facility staff for assistance. Additionally, based on interviews and observation, R1’s room had a mini refrigerator which contained water and food. Interview with the Administrator conducted on 11/03/2021, revealed that residents are never locked in their rooms. The Administrator explained that the residents’ rooms are lockable from the inside and out. The Administrator also explained that all residents have access to water, whether it’s from the dining room, lobby or staff directly bring water to residents’ rooms. 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 above allegations, “Resident did not have access to drinking water” and “Resident was locked in the room” are deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

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