197606845-8-14-2021-29-AS-JAPL-C5XVB2-20210816161650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 08/14/2021
Date Signed: 08/14/2021 11:37:05 AM

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
02/26/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20210226164742

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: 63	DATE:	08/14/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Cristina Gomez		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident was touched inappropriately while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced complaint visit to deliver the findings for the above allegation. The LPA met with Cristina Gomez and explained the reason for the visit.

On 2/26/2021, the Department received a complaint stating that due to lack of supervision, Resident #1 (R1) was sexually abused by a medical professional that is not employed by this facility. Community Care Licensing Division’s Investigations Branch (IB) Investigator Olivia Spindola was assigned to the case. On 3/1/2021, LPA Aja Richardson requested documents and took a physical plant tour via FaceTime. Investigator Spindola reviewed medical records on 3/30/2021, interviewed facility staff on 3/4/2021 at 10:30 a.m., 11 a.m., 11:45 a.m., 12:15 p.m., and 12:45 p.m.; interviewed R1 on 3/4/2021 at 1:15 p.m.; interviewed a family member for R1 on 4/28/2021 at 10:30 a.m.; and, interviewed representatives from an outside agency on 4/27/2021 at 1:00 p.m. and on 4/28/2021 at 10:20 a.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2021

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-20210226164742

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: 08/14/2021

NARRATIVE

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Interviews conducted and records review revealed that R1 was evaluated for physical therapy services on 2/15/2021 by a physical therapist (PT) not employed by this facility. R1 began receiving services due to experiencing severe pain to their right hip and knees. Interviews revealed that PT provided therapeutic services to R1 on 2/15/2021 and staff denied receiving reports from R1’s regarding their dissatisfaction with PT’s care nor did R1 comment anything out of the ordinary occurring during the session. Facility staff described R1 as someone who was outspoken and whom would speak up if they had a concern or opinion about care.

Interviews revealed conflicting stories as to what transpired during the physical therapy session on 2/19/2021. R1 claimed that during the 2/19/2021 session, PT applied cream to their right hip and subsequently touched them inappropriately. R1 also claimed that they tried to leave their bedroom, but the door was locked. R1 admitted during their interview that it was at their request for PT to conduct sessions with their door closed and without the presence of facility staff and stated that they informed staff of what transpired the morning of 2/25/2021. R1 stated that when PT arrived on 2/25/2021 for a third session, R1 told PT to leave. PT denied claims that they ever touched R1 inappropriately and claimed that they only ‘did their job’ in providing therapeutic services for R1. PT claimed that during both the 2/15/2021 and 2/19/2021 visits that several residents were observed going into R1’s room to utilize R1’s patio and that R1 was visited by facility staff on 2/19/2021.

Interviews with a family member of R1 and a professional whom administered care to R1 revealed that R1 has a history of trauma and post-traumatic stress disorder (PTSD) which may cause R1 to be oversensitive and overact if they interpret interactions from others as sexually inappropriate. In addition, due to R1’s mental health diagnosis it was alleged that R1 had a tendency to exaggerate events. It was confirmed that R1 indeed felt that the physical touch from PT was inappropriate, but there was insufficient evidence to state that it was sexual in nature.

Based on the investigation, there is insufficient evidence to support the claim that facility staff failed to protect R1, nor was there sufficient evidence to determine whether the incident as perceived by R1 occurred. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2021

LIC9099 (FAS) - (06/04)

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