197606845-3-6-2024-29-AS-EPEI-D352G5-20240306162233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:23:26 PM

Document Has Been Signed on 03/06/2024 04:23 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: 58	DATE:	03/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	04:30 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 Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. At 10:00 a.m., the LPAs met with the Administrator, Cristina Gomez and explained the reason for the visit. At 10:18 a.m., the LPAs, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. During the physical plant tour, the LPAs conducted interviews with seven (7) residents. KITCHEN: At 10:25 a.m., the LPAs observed the kitchen and dining area. Knives are stored in the locked kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of two-day perishable and seven-day nonperishable food. The LPAs observed emergency food and water located in a locked storage room outside the kitchen area. At 10:25 a.m., the hot water measured at 105.2-degree Fahrenheit. The menu was posted outside the dining area. Snacks and beverages are available for residents. BEDROOMS: The LPAs observed eight (8) randomly selected resident rooms throughout facility. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The LPAs observed restrooms in eight (8) resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was tested throughout the visit and measured within the required range. At 10:50 a.m., LPA Peraldi observed Room #22’s emergency pull cord in the restroom in disrepair. During the time of the visit, maintenance staff fixed the emergency pull cord and the LPA observed it to be in good repair. Continued on 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: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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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Document Has Been Signed on 03/06/2024 04:23 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as in light fixtures on the second floor, room #22’s emergency pull cord and inoperable water fountain were in disrepair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	The Administrator stated that the items will be fixed and in good repair by due date and will provide proof to the LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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: 03/06/2024

NARRATIVE

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COMMON AREAS: The LPAs observed common area to be relatively clean and properly furnished. The LPAs observed the fire extinguishers on both floors to be fully charged and last serviced on 12/21/2023. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. The LPA's observed required postings on the wall near the dining area. The facility's smoke alarms are hard wired, and the facility is equipped with sprinkler system. Fire alarm/sprinkler system was last tested on 08/08/2023 with the expiration date 03/31/2026. The LPA observed cameras installed in the hallways and common areas. At 11:10 a.m., the LPAs observed a loose light fixture in the second-floor hallway. During the time of the visit, maintenance staff fixed the light fixture, and the LPA observed it to be in good repair. At 11:14 a.m., the LPAs observed an inoperable water fountain on the second floor. The Administrator stated that the water fountain will be removed.

OUTDOOR SPACE: The LPAs observed the courtyard, which has a covered outdoor area for resident use. There are multiple emergency exits located throughout the facility on both floors. Passageways were free and clear from obstruction. The facility has an underground parking garage. Inside the garage there is additional storage areas and various items. The LPAs had a conversation with the Administrator regarding disposing of any items that are no longer in use that are stored in the parking garage. There were no bodies of water noted.

OTHER: Medications and first aid kits are located in a locked medication room. An additional first aid kit is located next to the main office. There is also a mail room behind the receptionist area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor closet. The laundry units are located inside the locked laundry room. The LPAs observed sufficient supply of Personal Protection Equipment (PPE).

Files: Between 12:35 p.m. and 2:33 p.m., the LPAs conducted a file review for eight (8) residents and six (6) staff. The Eight (8) resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. At 3:23 p.m., P&I money was reviewed. Six (6) personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Facility fire and disaster drill was last conducted on 02/20/2024. Administrator certificate is current and valid until 04/21/2024.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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: 03/06/2024

NARRATIVE

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Starting at 2:38 p.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents and observed that medications were properly documented and assisted with as prescribed.

Documentation: During the time of the visit, the LPAs obtained a copy of the liability insurance, surety bond, resident roster, staff roster, Infection Control Plan and Emergency and Disaster Plan.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

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