198603573-3-9-2023-28-AS-RORN-CQEMJV-20230330093944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603573
Report Date: 03/09/2023
Date Signed: 03/09/2023 01:31:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2023 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20230306115152

FACILITY NAME:	GOLD MEDAL SENIOR LIVING GARDENS		FACILITY NUMBER:	198603573
ADMINISTRATOR:	SANTOS, TONI		FACILITY TYPE:	740
ADDRESS:	311 NORTH MOUNTAIN AVE		TELEPHONE:	(714) 488-7542
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 4	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	Vicky Serna and Administrator Toni Santos		TIME COMPLETED:	01:36 PM

ALLEGATION(S):

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Facility not storing an adequate amount of food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Care Manager Vickii Serna explained the reason for the visit. Administrator Toni Santos arrived a short time later.

The investigation consisted of: LPA conducted interviews with Care Manager Vickii Serna, Staff 1 (S1) and Staff 2-3 (S2-S3) and residents 1-4 (R1-4). LPA collected copies of Staff and Client Rosters. Food shopping receipts for recent food shopping trips. LPA reviewed R1-R4 facility files, Week 1 menu and other documents pertinent to the complaint investigation. LPA additionally conducted a tour of the facility kitchen area, observed refrigerator contents and food storge areas.

Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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 28-AS-20230306115152

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLD MEDAL SENIOR LIVING GARDENS	FACILITY NUMBER: 198603573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/09/2023 Section Cited CCR 87555(b)(26)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply:(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility staff will purchase non perishable food for 7 days and provide evidence to LPA. **Non perishable food was purchased before LPA made visit and observed at time of visit, no further action required*
	8 9 10 11 12 13 14	2 staff stated that the facility did not keep suficent supply of 7days non perishabl because they try to provide fresh food for residents. Receipts show non perishable food purchased recently.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230306115152

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLD MEDAL SENIOR LIVING GARDENS	FACILITY NUMBER: 198603573
	VISIT DATE: 03/09/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Facility not storing an adequate amount of food. it is alleged that there is not enough food in the facility. Interviews conducted with 2 of 4 residents revealed that they are satisfied with the food service provided at the facility. Interviews with 3 of 3 staff denied that there is not sufficient food for residents. S1 and S3 stated that they lacked can goods because they mostly use fresh food to feed the residents. S3 stated they since have purchased additional nonperishable food for 7 days. Interview with W1 reveal W1 had no complaints regarding the allegation and stated the food is plentiful and good quality. Interviews with staff revealed that food is ordered every two weeks to ensure that there is enough food in stock for client's daily dietary consumption. S1 stated she shops for food every 2 weeks and they provide residents 3 meals a day plus snacks that include fruit, cookies, yogurt, tea, coffee cake and/or smoothies. LPA toured the facility kitchen and observed facility menu posted and observed an ample amount of food. There was enough food for 7 days non-perishable and 2-day perishables. Although there was sufficient non perishable food at the time of LPA's investigation, based on the information obtained through interviews, record review and shopping receipts. There was not enough non perishable for 7 days some days before LPA visit. Therefore, the allegation is Substantiated.

Citation issued on the 9099D. Exit interview conducted with Toni Santos and Vickii Serna and a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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