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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:30:17 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
09/18/2024 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20240918081213
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: 59DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Christina GomezTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility elevator is disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an initial complaint visit for the above allegation. LPA arrived to the facility at 12:33 p.m. met with staff and explained the reason for the visit. The Administrator, Cristina Gomez arrived at approximately 12:40 p.m. Entrance interview conducted and the reason for the visit was explained.

During today’s visit, the LPA conducted a physical plant tour to ensure there are no health and safety hazards, conducted interviews with the Administrator, three (3) staff members, and three (3) residents between 12:52 p.m. and 02:00 p.m., conducted file review at 02:05 p.m., and obtained copies of pertinent documents relevant to the investigation.

Continued on 9099C.
Unsubstantiated
Estimated Days of Completion: 7
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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-20240918081213
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: 09/18/2024
NARRATIVE
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It was alleged that the facility elevator is in disrepair. The LPA conducted a physical plant tour on 09/18/2024 at 12:41 p.m and observed one elevator in the facility that gives access to the 2nd floor. The facility also has a staircase with access to the 2nd floor. The LPA observed and used the elevator and confirmed that the elevator was functioning appropriately at the time of the visit. Record review revealed that the elevator was last serviced on 08/30/2024 and the last time the elevator was out of order, prior to 09/17/2024, was on 01/21/2024. Information obtained from interviews and record review confirmed that the elevator was inoperable on the evening of 09/17/2024. LPA interviewed three (3) residents and four (4) staff. Three (3) of three (3) residents live on the second floor of the facility and stated that the elevator has been inoperable in the past, but the issue is resolved by the next day. Four (4) of four (4) staff interviewed were knowledgeable on the protocol for an out of order elevator. Staff confirmed that they inform residents of an out of order elevator, place a sign on the doors to the elevator, and assist residents with ascending/descending the stairs if needed. Additionally, staff will bring meals and supplies to residents upstairs if they do not wish to utilize the stairwell. Based on the information obtained, when the elevator is not working the facility properly informs residents, offers residents assistance with mobility, and actively works to make repairs in a timely manner. The administrator confirmed that any residents needing assistance can be escorted by staff. Although the allegation may have happened or is valid there is not a preponderance of evidence to support the allegation. This allegation is deemed Unsubstantiated at this time.

No deficiencies were cited at the time of the visit. Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2