<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 03/04/2022
Date Signed: 03/12/2024 11:07:15 AM

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
09/08/2020 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20200908165039
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: 63DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cristina Gomez, AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident not administered medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This amended report was issued 03/12/2024 to correct a finding. Licensing Program Analyst (LPA) Emily Peraldi delivered amended report during office meeting with Administrator and Licensee.

Regarding the allegation ‘Resident not administered medication as prescribed' it was alleged that the facility staff was not properly assisting with the self-administration of medication as prescribed. Per the investigation, the Department substantiated this allegation on 03/04/2022. However, the licensee submitted an appeal dated 03/14/2022. After reviewing the appeal information, it was determined that the findings for the above-mentioned allegation would be changed from Substantiated to Unsubstantiated.

There will be no deficiencies as it relates this allegation ‘Resident not administered medication as prescribed’. Exit interview conducted. A copy of this report was issued.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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 3
Control Number 29-AS-20200908165039
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: 03/04/2022
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
26
27
28
29
30
31
32
*This page was intentionally left blank*
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20200908165039
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/11/2022
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
After reviewing the appeal information, it was determined that the findings for the above-mentioned allegation would be changed from Substantiated to Unsubstantiated.

Deficiency Dismissed
8
9
10
11
12
13
14
Based on interviews, record review and observations, the licensee did not comply with the section cited above, as the facility failed to assist with Resident #1’s (R1’s) and Resident #2’s (R2’s) self-administered medications per physicians order, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
**Amended report was issued 03/12/2024 to correct a finding.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3