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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 02/14/2022
Date Signed: 02/14/2022 03:30:59 PM


Document Has Been Signed on 02/14/2022 03:30 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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:
02/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Cristina Gomez, AdministratorTIME COMPLETED:
03:31 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 1:37 p.m., LPA met with Administrator Cristina Gomez and explained the reason for the visit.

The reason for today's inspection is to follow up on a self-reported incident report received on 02/14/2022. The report pertains to Resident #1 (R1) found deceased from a suspected suicide. An interview was conducted with the Administrator. The LPA also reviewed records at 1:45 p.m. and obtained copies of pertinent documents.

No immediate health and safety concerns were observed during today's inspection.

Further investigation is needed. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) and accepted on 02/14/2022. The investigation is assigned to Investigator Olivia Spindola. Exit interview conducted and report reviewed with the Administrator. A copy of the report will be emailed.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
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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