306004771-8-4-2022-22-AS-MSTC-CJS4FS-20220930190424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004771
Report Date: 08/03/2022
Date Signed: 08/04/2022 08:01:08 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2022 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220714132148

FACILITY NAME:	GOLDEN FLOWER MANOR, LLC		FACILITY NUMBER:	306004771
ADMINISTRATOR:	FLORICA GHEORGHE		FACILITY TYPE:	740
ADDRESS:	2411 E. LA PALMA AVE.		TELEPHONE:	(714) 215-4283
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2022
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:	Administrator Florica Gheorghe		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Administrator is refusing to surrender a resident's personal property.

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Administrator (AD) Florica Gheorghe.

Complaint alleges AD is refusing to surrender a resident's personal property.

Interview was conducted with Administrator (AD) Florica Gheorghe. During interview AD stated they contacted Elixair and Elixair had stated Hoyer lift did not belong to the company.

LPA also obtained Medicare Capped Rental Service Agreement from complainant and facility. Medicare Capped Rental Service Agreement states, “Medicare will pay a monthly fee for a period not to exceed 13 months, after which ownership of all equipment is transferred to the Medicare beneficiary.”
(Cont. on LIC9099-C)

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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 22-AS-20220714132148

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN FLOWER MANOR, LLC	FACILITY NUMBER: 306004771
	VISIT DATE: 08/03/2022

NARRATIVE

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LPA contacted Elixiar, the company which issued the Hoyer lift. LPA spoke with an Elixair Representative (ER) and was able to confirm, based on the serial number observed on the electric Hoyer lift located in the dining area of the facility, the Hoyer lift is R1’s property.

The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated by the California Code of Regulations, Title 22, section 87217(i). Per disclosures made during interviews, and records obtained by LPA it was determined that AD is refusing to surrender R1’s personal property.

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220714132148

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN FLOWER MANOR, LLC	FACILITY NUMBER: 306004771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/01/2022 Section Cited CCR 87217(i)	1 2 3 4 5 6 7	87217 Safeguards for Resident Cash, Personal Property, and Valuables... (i) Upon discharge of a resident all… personal property and valuables of that resident… shall be surrendered to the resident, or his responsible person.	1 2 3 4 5 6 7	Administrator (AD) Florica Gheorghe stated responsible person for Resident 1 (R1) can pick up the Hoyer lift anytime. AD will notify LPA once Hoyer lift has been picked up no later than POC date 9/01/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on interviews and observation licensee did not surrender personal property to resident or their responsible person.	8 9 10 11 12 13 14
ILS	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC9099 (FAS) - (06/04)

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