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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603573
Report Date: 06/19/2025
Date Signed: 06/19/2025 12:27:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
06/03/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250603185335
FACILITY NAME:GOLD MEDAL SENIOR LIVING GARDENSFACILITY NUMBER:
198603573
ADMINISTRATOR:SANTOS, TONIFACILITY TYPE:
740
ADDRESS:311 NORTH MOUNTAIN AVETELEPHONE:
(714) 488-7542
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Victoria Serna House ManagerTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff did not ensure that resident was adequately fed
Staff did not ensure that resident had a call button that was operable
Staff mismanaged resident medication
Staff do not respond to resident's call for assistance in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with House Manager Victoria Serna and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 06/10/2025, LPA interviewed Administrator, Staff #1- Staff #3, Residents #1 -Residents #3, checked food supply, check that call buttons were working, and checked R1’s medication for any errors or discrepancies. LPA obtained copies of the following documents: Staff roster, Resident roster, R1’s Physicians report, identification and emergency information, and emails between staff and POA for R1. During today’s visit LPA Gutierrez delivered findings.

SEE 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20250603185335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLD MEDAL SENIOR LIVING GARDENS
FACILITY NUMBER: 198603573
VISIT DATE: 06/19/2025
NARRATIVE
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In regard to the allegation “Staff did not ensure that resident was adequately fed”, it is alleged that staff is not feeding residents a balanced nutritional meal. During interviews with Administrator and staff four (4) out of four (4) staff stated that all residents are always fed nutritional meals with fresh fruits and vegetables. Administrator stated that some family’s advise facility what their family member can and cannot eat. During interviews with residents three (3) out of three (3) residents stated that food is okay and that they are fed enough LPA did a tour of food supply and there was a sufficient supply of 2-day perishable foods and 7 day non-perishable foods with a variety of fresh fruits such as strawberry’s, grapes, watermelon, oranges, fresh vegetables such as lettuce, carrots celery and bell peppers, and whole grains.

In regard to the allegation “Staff did not ensure that resident had a call button that was operable”, It is alleged that R1’ s call button was taken away for pushing it to many times and that when POA came and pushed button it did not work”, During interviews with Administrator and staff four (4) out of four (4) staff stated call button was never taken away from R1 and that staff had informed R1”s POA that resident had a hard night and call button was pressed repeatedly. Staff also stated that R1 has a call button in bedroom restroom and a call alarm on seat recliner. S1 stated that batteries may have died and were changed immediately. During interviews with residents two (2) out of three (3) stated that call buttons work, and staff responds when called. R3 did not have a call button. LPA tested residents call buttons and both were working at time of visit.

In regard to the allegation “Staff mismanaged resident medication”, it is alleged that a Tylenol pill was found on floor of R1’s bedroom floor. During interviews with Administrator and staff four (4) out of four (4) stated they pass out medication to residents and ensure that they are taken. Staff did state that R1 sometimes refuses medication but does not know how pill was on floor. During interviews with residents three (3) out of three (3) stated that they have never had any medication problems with staff. R1 stated “I’m not a baby” when asked if staff watched when he/she took medication. LPA conducted a medication check and found no discrepancies. Facility uses a house supply of Tylenol.

SEE 9099C

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250603185335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLD MEDAL SENIOR LIVING GARDENS
FACILITY NUMBER: 198603573
VISIT DATE: 06/19/2025
NARRATIVE
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In regard to the allegation “Staff do not respond to resident's call for assistance in a timely manner “, it is alleged that when POA pressed call button nobody came 15 minutes later button was pressed again and no response. During interviews with Administrator and staff four (4) out of four (4) stated that R1 had been pressing call button repeatedly through the night and that might have caused button batteries to die. Staff stated that as soon as it was brough to their attention batteries were changed. During interviews with residents two (2) out of three (3) residents stated that staff responds when they press there call button. R2 stated that they rely on their call button too much. R3 does not use a call button.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to House Manager Victoria Serna.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3