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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:09:19 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
12/14/2023 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20231214144739
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: 60DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Christina GomezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility does not provide a safe environment for the residents in care
Facility staff did not prevent a resident from falling
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 09:31 AM, the LPA met with facility staff who contacted the Administrator, Cristina Gomez via telephone call. The Administrator arrived to the facility at 09:58 AM, entrance interview conducted and the reason for the visit was explained.

During the initial visit conducted on 12/20/2023 between 10:00 AM and 3:00 PM, LPA Emily Peraldi and LPA Brian Balisi conducted a physical plant tour and interviews with the Administrator, seven (7) residents, and four (4) staff. During the initial visit, the LPAs also obtained copies of pertinent documents. During a follow-up visit on 11/22/2024, between 09:45 AM and 12:35 PM, LPA Byrne conducted a physical plant tour, conducted interviews with six (6) residents, the facility Administrator, and six (6) staff. During today’s visit between 10:00 AM and 12:05 PM LPA Byrne conducted a brief physical plant tour, obtained copies of pertinent documentation, and interviewed the facility Administrator, three (3) staff, and three (3) residents.
Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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-20231214144739
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: 12/16/2024
NARRATIVE
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Regarding the allegations: Facility does not provide a safe environment for the residents in care and Facility staff did not prevent a resident from falling. On 12/14/2023, the Department received a complaint alleging that the facility’s elevator being in disrepair created an unsafe environment for the residents in care by forcing them to utilize the stairs which caused a resident to fall. During today’s visit LPA Byrne interviewed the Administrator who provided the LPA with the incident report that was submitted to CCLD regarding the incident referenced in the complaint. Based on the information obtained from the incident report and the interview with the Administrator, LPA Byrne determined that the fall occurred as a result of a medical emergency and did not occur on or near the facility elevator or stairs. Additionally, the Administrator stated that once staff were notified of the fall, they immediately moved in to assist the resident and initiated a 911 call. Interviews with three (3) residents and three (3) staff revealed that the facility took actions to mitigate the risks posed by the elevator being out of service. These actions included: Placing out of order signs on the facility elevator that instructed residents to contact staff for assistance ascending/descending the stairs, bringing food/water/medications to residents on the second floor, and increasing the staffing ratios to account for the increased supervision needs. One (1) resident interviewed stated that during the time that the elevator was out of order they had asked staff for assistance descending the stairs multiple times. The resident stated that staff responded immediately and always assisted them when asked. Additionally, one (1) resident, who did not utilize staff assistance descending the stairs, stated that they observed staff members assisting residents during the period that the elevator was out of order. Three (3) staff members stated that they were present and assisting residents with ascending/descending the facility stairs at that time. Additionally, the staff confirmed the presence of out of order signs instructing residents to seek staff assistance and the increase of staffing ratios to account for the increased supervision needs of the residents. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations that the facility does not provide a safe environment for the residents in care and facility staff did not prevent a resident from falling. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2