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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004771
Report Date: 10/10/2024
Date Signed: 10/10/2024 04:57:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
10/08/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241008082533
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:
10/10/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Florica GheorgheTIME COMPLETED:
01:29 PM
ALLEGATION(S):
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Uncleared adults providing care to residents
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Jerome Haley and William Vanegas made an unannounced visit to begin the investigation into the complaint allegation above. LPAs were greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews with facility staff, residents, document review, and observations.
Regarding the complaint allegation: Uncleared adults providing care to residents

During the investigation LPAs observed an uncleared and unassociated adult working in the facility. The Uncleared Individual (UI1) adult was in the kitchen when LPAs entered the facility. UI1 provided their first and last name, and a date of birth. U1 stated they have been working at the facility since April 2024. UI1 was asked for their ID and UI1 said they did not have any ID. Upon review of the Guardian system and personnel print out of all the employees associated to Golden Flower Manor, UI1 was not listed on either personnel report.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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-20241008082533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN FLOWER MANOR, LLC
FACILITY NUMBER: 306004771
VISIT DATE: 10/10/2024
NARRATIVE
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A fingerprint clearance and LIC501 was requested for UI1, however the information provided was for an individual with a different name and different date of birth.

Based on the evidence gathered through interviews and observations, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.

An exit interview was conducted, and a copy of this report, and appeal rights were provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241008082533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
87355(e)
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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidence by:
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Licensee agrees to review regulation section 87355 Criminal Record Clearance and send LPA Haley a signed statement of acknowledgement and understanding. In the statement of understanding Licensee provide a statement acknowledging they understands the Unidentified Individual 1 (UI1) is not to be allowed in the facility until UI1 has a criminal background clearance and is associated to the facility personnel roster.
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Unidentified Individual 1 (UI1) was observed working in the facility upon LPAs arrival. UI1 does not have a criminal background clearance and was not associated to the facilities personnel roster. This poses a 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3