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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:57:48 PM

Unsubstantiated


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
01/02/2024 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20240102155058
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: 66DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Christina GomezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff does not provide quality food to residents.
Staff does not provide resident with quality drinking water.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 09:45 a.m., the LPA met with Administrator, Cristina Gomez and explained the reason for the visit.

During the initial visit conducted on 01/10/2024 between 9:30 a.m. and 3:00 p.m., LPA Emily Peraldi conducted a physical plant tour and interviews with the Administrator, ten (10) residents, and three (3) staff. During today’s visit, between 09:45 a.m. and 12:35 p.m., LPA Byrne conducted a physical plant tour, conducted interviews with six (6) residents, the facility Administrator, and six (6) staff.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion: 7
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 2
Control Number 29-AS-20240102155058
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: 11/22/2024
NARRATIVE
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This amended report supersedes the report issued on 11/22/2024.

Regarding the allegation: Staff does not provide quality food to residents. On 01/02/2024, the Department received a complaint alleging the food being served as “not good.” During physical plant tours conducted on 01/10/2024 and 11/22/2024, the LPAs did not observe expired food or moldy food. Resident interviews conducted on 01/10/2024 and 11/22/2024, did not reveal any concerns regarding the food being served. 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 sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.



Regarding the allegation: Staff does not provide resident with quality drinking water. On 01/02/2024, the Department received a complaint alleging that the drinking water “taste funny.” Interviews conducted with residents on 01/10/2024 and on 11/22/2024 revealed that residents do not have any concerns regarding their drinking water. During interviews with the Administrator, they explained that the water filter is changed every 4 months. Additionally, the Administrator stated that residents can request bottled water if they do not want the drinking water provided. On 11/22/2024 LPA Byrne observed signs posted throughout the facility informing residents that bottled water is provided at their request. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time.

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

A copy of this amended report was emailed to the administrator for signature.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
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