197606845-6-18-2021-29-AS-KHEN-C6DSUF-20210830141102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 06/18/2021
Date Signed: 06/18/2021 04:53:35 PM

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
06/11/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20210611111600

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: 64	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Cristina Gomez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility is poisoning resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Emily Peraldi and KaSandra Lopez conducted an unannounced 10-day inspection to investigate the above allegation. At 10:08 am, LPAs were screened and greeted by receptionist, Claudia Sandoval. At 10:35 am, the LPAs met with Administrator Cristina Gomez and explained the reason for today's inspection.
Beginning at 10:23 am, LPAs conducted record review for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4). At 11:17 am, LPAs toured the facility with Administrator. At 11:25 am, LPAs toured the kitchen and food storage areas. During the inspection, fire extinguishers were observed to be fully charged and last serviced on 04/30/2021. Between 11:45 am and 12:45 pm, LPAs conducted a medication review for seven residents out of sixty-four residents. Between 12:53 pm and 1:52 pm, LPAs interviewed seven residents out of sixty-four residents. Between 1:53 pm and 2:50 pm, LPAs interviewed seven staff, (Staff #2, Staff #3, Staff #4, Staff #5, Staff #6, Staff #7,) including the Administrator. Staff #1 was unavailable for interview today. At 2:50 pm, LPAs reviewed Staff #1’s (S1) file.
Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210611111600

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: 06/18/2021

NARRATIVE

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The allegation of “Facility is poisoning resident” alleges Resident #1 (R1) is being poisoned by staff through their food and medications. The allegation also alleges that R1 was made sick by Staff #1 (S1) due to their hygiene practices. S1 works in the kitchen. During the inspection of the kitchen and food storage area, food was observed to be of good quality, stored properly and at their appropriate temperatures. Cleaning supplies and disinfectants were observed to be stored separately from the food. During resident interviews, six out of seven residents, had no complaints or issues regarding the food being served or issues or concerns regarding medications.

During the medication review, seven out of seven resident medications were observed to be administered and documented properly. No poisonous substances were observed in the medication room.

During the staff interviews, two out of the eight staff interviewed were aware of issues between R1 and S1, including an incident on 05/27/2021 where R1 was aggressive towards S1 and verbally abusive towards other staff and was placed on a 5150 hold. Staff interviewed were not aware of any food complaints or medication concerns by any other residents. Staff also stated there were no hygiene concerns with any staff, including S1.

During R1’s file review there was no evidence to support R1 was being poisoned or sick due to food or medications being provided at the facility. On 05/13/2021, R1 went to the hospital for stomach pain and was diagnosed with no acute findings. On 5/28/2021, R1 was medically cleared to be admitted to a psychiatric facility.

During the interview with administrator, she was unaware of R1 being sick due to being poisoned through their food or medications.

Based on this information, there’s insufficient evidence to support the allegation occurred. Therefore, the allegation is Unsubstantiated at this time.

Exit interview conducted and report reviewed with Administrator. A copy of the report will be emailed by the end of the day.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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