197606845-12-6-2024-29-AS-TBYE-DBPTSD-20241206135857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 12/06/2024
Date Signed: 12/06/2024 01:59:05 PM

Document Has Been Signed on 12/06/2024 01:59 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/ DIRECTOR:	CRISTINA GOMEZ		FACILITY TYPE:	740
ADDRESS:	10537 MAGNOLIA BLVD.		TELEPHONE:	(818) 761-5777
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91601
CAPACITY: 100	TOTAL ENROLLED CHILDREN: 0	CENSUS: 59	DATE:	12/06/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Christina Gomez		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:10 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility Administrator Christina Gomez entrance interview conducted and the reason for the visit was explained.

During the physical plant tour the LPA observed the facility’s refrigerator. At 09:16 AM LPA observed moldy strawberries. At 09:34 AM LPA observed the facility’s emergency food supply to contain 11 cans of expired peaches. LPA measured the water in twenty-one (21) resident bathrooms between 09:38 AM and 11:20 AM. Four (4) resident bathroom’s water temperatures were measured between 97.3 and 102.4 degrees Fahrenheit which is below the allowable temperature of 105 degrees Fahrenheit. Four (4) resident bathroom’s water temperatures were measured between 120.6 and 131.7 degrees Fahrenheit which is above the allowable temperature of 120 degrees Fahrenheit. At 10:04 AM and 10:31 AM LPA observed two (2) screen doors located in resident rooms to contain tears in the screen material.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited. (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Trevor Byrne	TELEPHONE: 747-444-6104
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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 12/06/2024 01:59 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: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents... attain a temperature of not less than 105... and not more than 120 degree F... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Facility Administrator will conduct a test of all resident bathrooms and create a temparature log. An appropriately skilled plumber is scheduled to perform work to the facility's plumbing on 12/09/2024. Administrator will submit proof of completed repairs and temp log to CCLD no later than POC due date.

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.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Trevor Byrne	TELEPHONE: 747-444-6104
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2024 01:59 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: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Identified screen doors were repaired at the time of the visit POC cleared.

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.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Trevor Byrne	TELEPHONE: 747-444-6104
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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