197606845-12-20-2023-29-AS-EPEI-CYPUEU-20231220143142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:33:00 PM

Document Has Been Signed on 12/20/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 64	DATE:	12/20/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Emily Peraldi and Brian Balisi conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with the Administrator and explained the reason for the visit. On 02/14/2022, the Department received an incident report regarding the possible suicide of Resident #1 (R1). The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Olivia Spindola to determine whether the licensee was culpable for lack of care and supervision which resulted in the death of R1. On 02/14/2022, from 1:37pm to 3:31pm, Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 1:37pm, LPA Peraldi met with the Administrator Cristina Gomez and explained the reason for the visit was to follow up on a self-reported incident report received on 02/14/2022. The report pertained to Resident #1 (R1) who was found deceased from a suspected suicide. The LPA interviewed the Administrator, reviewed records at 1:45pm, and obtained copies of pertinent documents. The LPA determined further investigation was needed and informed the Administrator that the complaint investigation was assigned to the Community Care Licensing (CCL) Investigations Branch (IB) Investigator Olivia Spindola. On 03/18/2022, from 11:30am to 1:20pm, Investigator Spindola conducted interviews with the Administrator, staff, and residents; and on 05/12/2022, at 8:15am, with staff. Additionally, Investigator Spindola requested Los Angeles Coroner’s Medical Examiner and Los Angeles Police Department reports; requested and reviewed medical records and facility file documents related to R1. Continued LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/20/2023

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A review of R1’s Physician Report, dated 04/27/2021, lists R1’s primary diagnoses as Depression, Anxiety, Hypertension, Osteoporosis, and Hypothyroidism. The report indicates R1 was ambulatory, had mild cognitive impairment, was able to manage their own treatment, medication, and equipment, had the capacity for all self-care, and was able to leave the facility unassisted.

The investigation revealed that on 02/14/2022, at approximately 06:30am, Staff #1 (S1) was cleaning the patio area of the facility. When S1 looked up towards the second floor, S1 saw R1 hanging by their neck with a nylon rope from R1’s second story balcony rails. S1 immediately ran to R1 and when S1 touched R1’s feet to assist, S1 noticed R1 was cold to the touch and the body was lifeless. S1 yelled for help, Staff #2 (S2) and Staff #3 (S3) ran to S1’s location. Once the staff verified that R1 was deceased they called 911 and the facility Administrator. R1's body was removed from the facility by the Los Angeles Coroner's Office personnel.

The investigation further revealed that approximately six months earlier R1 told their friend, Resident #2 (R2), that their family member had 'forgotten about them, although they provided a good life for their family member.' The staff and residents were surprised R1 committed suicide, although R1 left a suicide note disposing of their belongings and saying goodbye to the staff. According to residents and staff, R1 was a very independent individual, owned a car, and would often leave the facility to go shopping or visit unknown locations. On 02/13/2022, during the late afternoon hours, when R1 returned to the facility with a shopping bag, R1 did not appear to be in any type of distress. Although it is unknown if the shopping bag contained the nylon rope R1 used to hang themself, it is likely that it did.

During the investigation, the Department did not find any evidence to indicate the facility staff neglected R1 in any form or knew R1 was suicidal, when R1 went to bed the previous evening. Therefore, the allegation “Neglect/Lack of Care and Supervision” is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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