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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004771
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:36:29 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, 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
02/28/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230228130808
FACILITY NAME:GOLDEN FLOWER MANOR, LLCFACILITY NUMBER:
306004771
ADMINISTRATOR:FLORICA GHEORGHEFACILITY TYPE:
740
ADDRESS:2411 E. LA PALMA AVE.TELEPHONE:
(714) 215-4283
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 2DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Florica Gheorghe - AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff yelled at a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation into the above allegation. LPA Velazquez was allowed entry into the facility and met with Administrator Florica Gheorghe and explained the purpose of the visit.

On today's visit LPA Velazquez conducted an interview with Administrator Gheorghe. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with Reporting Party, residents and staff. LPA Velazquez also reviewed resident and facility records. The records reviewed included Resident Identification and Emergency Information, Preplacement Appraisal Information, Resident Appraisals, Physician's Reports, Appraisal Needs and Services Plans, Resident (R) #1's Advance Health Care Directive, Durable Power of Attorney for Healthcare, and Victory Compassion Hospice records. Two of three individuals interviewed could not corroborate the above allegation. One of two individuals interviewed stated they were well-cared for by facility staff and indicated staff has not yet yelled at them or at any other resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
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 5
Control Number 22-AS-20230228130808
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: 04/06/2023
NARRATIVE
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Additional records reviewed included email communication from Reporting Party, copies of 2 checks with one dated January 23, 2023 for the amount of $5000 made payable to Golden Flower Manor and a second check dated February 21, 2023 for the amount of $6000 made payable to Golden Flower Manor, and a letter dated February 24, 2023 from R1's spouse notifying the facility that a stop payment was placed on the check for $6000. The letter also notified the facility of R1's spouse's intent to relocate R1 without issuing a 30 day notice to vacate the facility.


Based on the observations made by LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Staff yelled at a resident while in care is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Florica Gheorghe and a copy of this report along with the LIC 811 was provided at the time of this visit. Due to technical issues LPA Patricia Velazquez was not able to print the report at the time of this visit. Administrator Gheorghe agreed to receive the report via email.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/28/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230228130808

FACILITY NAME:GOLDEN FLOWER MANOR, LLCFACILITY NUMBER:
306004771
ADMINISTRATOR:FLORICA GHEORGHEFACILITY TYPE:
740
ADDRESS:2411 E. LA PALMA AVE.TELEPHONE:
(714) 215-4283
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 2DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Florica Gheorghe - AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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2
3
4
5
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8
9
Staff have inadequate record keeping for a resident
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation into the above allegation. LPA Velazquez was allowed entry into the facility and met with Administrator Florica Gheorghe and explained the purpose of the visit.

On today's visit LPA Velazquez conducted an interview with Administrator Gheorghe. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with Reporting Party, residents and staff. The records reviewed included Resident Identification and Emergency Information, Preplacement Appraisal Information, Resident Appraisals, Physician's Reports, Appraisal Needs and Services Plans, Resident (R) #1's Advance Health Care Directive, Durable Power of Attorney for Healthcare, and Victory Compassion Hospice records. Two of three individuals interviewed could not corroborate the above allegation. One of two individuals interviewed stated they were well-cared for by facility staff and indicated staff has not yet yelled at them or at any other resident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20230228130808
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: 04/06/2023
NARRATIVE
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Additional records reviewed included email communication from Reporting Party, copies of 2 checks with one dated January 23, 2023 for the amount of $5000 made payable to Golden Flower Manor and a second check dated February 21, 2023 for the amount of $6000 made payable to Golden Flower Manor, and a letter dated February 24, 2023 from R1's spouse notifying the facility that a stop payment was placed on the check for $6000. The letter also notified the facility of R1's spouse intent to relocate R1 without issuing a 30 day notice to vacate the facility. Administrator Gheorghe stated they did not provide R1 or their Responsible Person written notice of the rate increase that included a detailed explanation of the additional services to be provided at the new level of care including an accompanying itemization of the charges pursuant to statute and regulation.


Based on the observations made by LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff have inadequate record keeping for a resident is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 and/or the Health and Safety Code is being cited on the attached LIC 9099D.




An exit interview was conducted with Administrator Florica Gheorghe and a copy of this report along with the LIC 811 and appeal rights were provided at the time of this visit. Due to technical issues LPA Patricia Velazquez was not able to print the report at the time of this visit. Administrator Gheorghe agreed to receive the report via email.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230228130808
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: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
HSC
1569.657(a)
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Rate increase due to change in level of resident care; notice. For any rate increase due to a change in the level of care of the resident...notice shall include a detailed explanation of the additional services to be provided at the new level of care and an
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Licensee to ensure it adheres to statute and regulation at all times as it relates to rate increase due to change in level of resident care.
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accompanying itemization of the charges. This requirement is not met as evidenced by: based on interview & record review the Licensee did not provide a statement including the itemization of charges. This poses a potential risk to the health & safety of residents in care.
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Licensee to submit a written statement to LPA indicating how they intend to adhere to this statute by POC due date.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5