197606845-1-6-2022-29-AS-KHEN-CFTVWU-20220628164831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 01/06/2022
Date Signed: 01/06/2022 03:18:15 PM

Unsubstantiated

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
12/29/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20211229115205

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:	01/06/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cristina Gomez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not serve resident with 60 notice for rate increase

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced 10-day initial complaint visit at the facility today. At 9:30 a.m., LPA met with facility staff and explained the reason for the visit. At 9:42 a.m., Administrator Cristina Gomez arrived at the facility.

At 10:12 a.m., LPA and Administrator toured the facility. The LPA also reviewed records at 9:45 a.m. and obtained copies of pertinent documents. Between 10:26 a.m. – 11:47 a.m., LPA interviewed residents and staff.

The allegation, that ‘Facility did not serve resident with 60 notice for rate increase’ alleges that the facility did not serve Resident #1 (R1) a 60-day written notice prior to the Social Security Income (SSI) rate increase which became effective January 1, 2022. Per record review and interviews, the facility provided written notice to the residents – including R1 – about the rate increase on December 1, 2021.
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: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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-20211229115205

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: 01/06/2022

NARRATIVE

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Continued from LIC 9099.

In addition, the facility provided residents whom needed further explanation a copy of the Provider Information Notice (PIN) 21-23-CCLD, which describes the estimated SSI rate increase (Described as PIN 21-23-CCLD ESTIMATED SSI/SSP PAYMENT STANDARDS EFFECTIVE JANUARY 1, 2022).

Per regulation, licensees are required to provide residents with at least a sixty (60) day notice regarding any rate increase or rate structure change. However, facilities are not required to provide a sixty (60) day notice when it pertains to SSI rate changes. Thus, the Provider Information Notice (PIN) was issued on 11/19/2021, informing licensees that the rate change would be in effect 1/1/2022. That change would be in effect under sixty (60) days. The facility is required to notify residents as soon as the licensee is notified of SSI/SSP rate change.

Based on the information obtained, there is insufficient evidence to support the claim, as the rate increase was based on SSI changes, which were communicated to the licensee less than sixty days from the effective date. This allegation is deemed Unsubstantiated at this time.

Exit interview conducted and report reviewed with Administrator. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC9099 (FAS) - (06/04)

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