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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004771
Report Date: 09/04/2024
Date Signed: 09/04/2024 10:09:39 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
08/30/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240830154950
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: 5DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Florica GheorgeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility did not provide adequate notice of rate change to resident and/or POA
Facility did not discuss/inform POA of Resident's change in condition and or level of care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA toured the facility and interviewed Administrator. Regarding the allegations that facility did not discuss/inform POA of Resident's change in condition and/or level of care and facility did not provide adequate notice of rate change to resident and/or POA, the investigation revealed the following: Facility Administrator provided a notice of rate increase of $1000 to Resident 1's (R1) responsible party on 08/27/2024 and effective 09/01/2024 for an increase in level of care. While the notice was provided to responsible party, the notice did not include a detailed explanation of additional services to be provided nor an accompanying itemization of the charges. R1's physician report dated 01/05/2024 indicates a diagnosis of Dementia with total dependence of activities of daily living. Facility did not conduct a reappraisal of the resident nor conduct a meeting with resposible party along with the care team. Based on records reviewed, The preponderance of evidence standard has been met; CONT ON LIC 9099C DATED 09/03/2024
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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 22-AS-20240830154950
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: 09/04/2024
NARRATIVE
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Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240830154950
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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
HSC
1569.657(a)
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For any rate increase due to a change in the level of care.., written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This req is not being met as evidenced by:
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Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.
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Based on record review, Licensee failed to ensure a detailed explanation of services along with itemization of charges was provided. This poses a potential health and safety risk to residents in care.
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Type B
09/18/2024
Section Cited
CCR
87463(c)
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The licensee shall arrange a meeting with the resident, the resident’s representative.., when there is significant change in the resident’s condition,.., as specified in Section 87467, Resident Participation in Decision Making. This requirement is not being met as evidenced by:
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Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.
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Based on record review, Licensee failed to ensure a re-appraisal was conducted and discussed with responsible party. This poses a potential health and safety risk to residents in care.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3