197606845-10-6-2021-29-AS-KHEN-CCETYU-20220311140920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 10/06/2021
Date Signed: 10/06/2021 03:36:40 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
10/04/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20211004124104

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: 65	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Cristina Gomez - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not maintain accurate resident records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint investigation for the above allegation. Upon arrival LPA was greeted by Administrator Cristina Gomez and explained the reason for the visit.
Between 3:00 - 4pm, LPA conducted physical plant, interviewed staff and resident. LPA also reviewed and obtained copies of pertinent documents relevant to the investigation.
It was alleged that facility staff did not maintain accurate resident records. LPA records review and interview with Resident 1 (R1), revealed that upon admission to the facility R1 signed and confirmed that information observed and reviewed on form LIC 601 was accurate at that time. LPA records review of R1's discharge paperwork from previous stay, revealed that R1's information was obtained from discharge paperwork and inputted onto R1's LIC 601. Administrator stated they will sit down with R1 and review R1's records. Based on information obtained during this visit, there’s insufficient evidence to support the allegation facility staff did not maintain accurate resident records occurred. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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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