197606845-8-1-2023-29-AS-DPEA-CUWSNH-20230821140134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 08/01/2023
Date Signed: 08/01/2023 02:09:50 PM

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
07/27/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230727120155

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: 61	DATE:	08/01/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff stole resident’s mail.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit at the facility today. At 10:00 a.m., the LPA met with staff and explained the reason for the visit. At 10:24 a.m., the Administrator arrived at the facility.

During today’s visit, between 10:09 a.m. and 11:13 a.m., the LPA conducted interviews with six (6) out of sixty-one (61) residents and three (3) staff. At 10:25 a.m., the LPA conducted an interview with the Administrator. At 10:38 a.m., the LPA obtained copies of pertinent documents. During today’s visit, at 10:45 a.m., the LPA along with the Administrator conducted a physical plant tour.

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: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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-20230727120155

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: 08/01/2023

NARRATIVE

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Regarding the allegation: Staff stole resident’s mail. On 07/27/2023, the Department received a complaint alleging that Resident #1 (R1)’s mail is being stolen by staff. During the interview with the Administrator, it was revealed that residents go to the front desk to retrieve their mail. The mailbox area is located inside the Assistant Administrators office, and it is for employees only. The Administrator explained that staff are always present at the front desk and offices to assist residents with their mail. The Administrator stated that for packages being delivered to the facility, the residents sign a Package Receive Form once staff deliver residents their package. The Administrator provided copies of the recent Package Receive Form, dated 07/23/2023-07/31/2023. Lastly, the Administrator stated that they have not heard of concerns of staff stealing resident’s mail from staff or from residents. Interview with R1 conducted during today's visit revealed inconsistent statements regarding their mail, however, R1 could not provide details regarding the alleged stolen mail. Additionally, interviews with various residents revealed that they do not have any concerns regarding their mail being stolen or lost. Also, during same day interviews with various staff members denied the allegation of staff stealing R1’s mail or any resident mail. 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 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: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

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