Golden Flower Manor

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Allegation investigated: -Staff did not respond to a resident's call button in a timely manner -Staff do not ensure the residents toileting needs are met -Staff do not treat resident with dignity and respect -Staff did not ensure resident was provided with clean linen and or bedding -Staff did not report incident to responsible party -Unlawful eviction

On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to the facility for the purpose of delivering the findings of the above-mentioned allegations. Additionally, LPA conducted an initial 10-day inspection on March 13, 2026; during initial inspection LPA conducted interviews with staff on duty, and residents in care. Furthermore, LPA gathered pertinent documents related to allegations listed above. On today’s date LPA was greeted and granted entry into the facility by caregiving staff after introducing himself and stating the purpose for the visit. LPA began to explain the detailed information of the findings. LPA Vanegas explained the following. In reference to the allegation stating Staff did not respond to a resident’s call button in a timely manner the following has been determined. LPA conducted an Interview with staff 1 (S1) and the interview revealed the following: S1 states that they respond to resident’s calls for assistance within five to ten seconds; S1 states that they are always in close proximity and can hear the call bell right away. S2 states that if they are assisting another resident as soon as they are available they assist the other resident calling for help; however the wait time is never longer than five minutes. CONTINUED ON LIC9099C. Unsubstantiated S3 states that they have observed staff members responding as soon as possible. Interview with Resident 2 (R2) revealed the following: R2 states that the staff are doing just fine. They come to the residents aid as quickly as they can. Interview with Resident 3 (R3) revealed the following: R3 was non verbal, however was able to nod yes or no when questions were asked. R3 noted “yes” when asked if staff help them with their everyday needs. Based on interviews conducted the following allegation is deemed to be unsubstantiated. Although the allegation may have or may not have occurred the preponderance of evidence has not been met Regarding the allegation that states Staff do not ensure the residents’ toileting needs are met the following was revealed: LPA conducted an interview with S1 that revealed the following. S1 states staff are changing briefs as soon as they are requested to be changed by residents or when they are conducting their daily checks. Interview with S2 revealed the following. S2 states that staff clean residents as soon as possible, and they ensure that all resident needs are being met. Interview with S3 revealed the following. S3 states that they have observed staff on duty cleaning residents as soon as possible. Interview with complainant revealed the following. Complainant states that they do not assist R1 with toileting needs in a timely manner, and they left R1 in soiled sheets and briefs for an extended period of time. Based on interviews conducted and observations made by LPA the following allegation is deemed to be unsubstantiated. Although the allegation may have or may not have occurred the preponderance of evidence has not been met. Regarding the allegation stating Staff do not treat resident with dignity and respect Interviews conducted revealed the following: Interview with S1 revealed the following. S1 states that they treat residents with respect, and S1 states that they go above and beyond for the residents in care. The interview with S2 revealed the following S2 states that they have never yelled at or disrespect any residents in care nor have they witnessed any staff committing this type of behavior. S2 states that some staff have strong voices, and they feel that this may be interpreted as being rude or disrespectful. The interview with S3 revealed the following: S3 states that they have never witnessed any staff yelling at or being rude to residents in care. The interview with the complainant revealed the following: Complainant states that the Administrator was being very rude to R1 and was threatening to have R1 out of the facility by the end of the night. Interview with R2 revealed the following: R2 states that they feel that they are treated with dignity and respect. Interview with R3 revealed the following: R3 nodded yes when asked if staff are nice to them. Based on interviews conducted the following allegation is deemed to be unsubstantiated. Although the allegation may have or may not have occurred the preponderance of evidence has not been met. CONTINUED ON Additional LIC 9099C. In regard to the allegation Staff did not ensure resident was provided with clean linen and or bedding the following was concluded: Interview with S1 revealed the following. S1 states that they change bedding and linens upon request and when ever they observe that they need to be changed due to an accident. Interview with S2 revealed the following: S2 states that they change linens on a daily basis and upon request of the residents. Interview with S3 revealed the following: S3 states that they observe staff in care changing linens when ever they are at the facility for training. Interview with R2 revealed the following. Staff on duty change their linens when they ask them to. Interview with R3 revealed the following. R3 nodded yes when asked if linens are changed often. Based on interviews conducted the following allegation is deemed to be unsubstantiated. Although the allegation may have or may not have occurred the preponderance of evidence has not been met. Regarding the allegation Staff did not report incident to responsible party. The following was concluded. The interview with S1 revealed the following: S1 states they were on the phone the entire time with R1’s responsible party when R1 was being transported from the facility to the hospital via ambulance. S1 states that the paramedics gave complainant the name of the hospital of where R1 was being transported and once they left S1 had no way of knowing where the resident was being transported to if they were to be transported to a different hospital as mentioned by emergency responders. Interview with complainant revealed the following: Complainant states that resident was taken to the hospital via ambulance, but they were not notified to which hospital R1 was being taken too. Complainant states that they were on the phone, but they were given the wrong hospital name and later Administrator did not provide them with the name of the hospital R1 was transported too. Based on interviews conducted the following allegation is deemed to be unsubstantiated. Although the allegation may have or may not have occurred the preponderance of evidence has not been met. Regarding the allegation stating Unlawful Eviction. The following has been concluded. LPA conducted interview with S1 and the interview revealed the following. S1 states that resident was not evicted. S1 states that Complainant requested for R1 to be sent to the hospital for three days in order for R1 to qualify for admittance into their previous facility. S1 states that resident had been requesting to go back to their long term care facility since the moment they were admitted into this facility. S1 states that R1’s family wanted R1 back at R1’s original long term care facility, but they were unable to due so unless resident is sent to the facility by a hospital. S1 states that R1’s responsible party is the one who requested for the resident to be sent to the hospital in order to be moved back into the long term care facility of their choice. Interview with complainant revealed the following. Complainant states that Administrator stated that R1 was complaining to much, and that Administrator was stating that they did not want R1 at their facility anymore. Complainant states that Administrator advised complainant to come pick up resident or she will be out of the facility by the end of the night. Complainant states that S1 did notify them about the process to get R1 back into the long term care facility, however they did not feel that the Administrator calling the ambulance to get her out was justified. Based on interviews conducted the following allegation is deemed to be unsubstantiated. Although the allegation may have or may not have occurred the preponderance of evidence has not been met. The hospitalization was not justified. Complainant admitted that Administrator advised her that the only way resident would be accepted into long term care facility again is if they are hospitalized for three days or more. Administrator stated that Complainant requested for this to be done in order for Resident to be admitted back into LCF. Furthermore reporting party states that the resident is now in the long-term care facility again. Based on observations made, and interviews conducted, the following allegations are deemed to be unsubstantiated. Although the allegations may have or may not have occurred the preponderance of evidence has not been met. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 22-AS-20260305104334

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87629(b)(1) · Plan of correction due date: Jul 10, 2026

In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: Administrator will conduct training to ensure that staff are updated on the policies for inectable medications, and who can asisst and can not asisst with injections. Administrator will send proof of correction to LPA prior to POC due date Via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 1pm. LPA met with Administrator (AD) Flor Gheorghe and explained the purpose of the visit. The facility is a four bedroom, two bathroom residential home with an approved fire clearance for six non-ambulatory residents. There is also a separate area where the Administrator resides with an additional bedroom, living area and bathroom. There are currently six residents in care and two on hospice. The facility participates in the Assisted Living Waiver (ALW) Program. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms. The hot water temperature measured between 109.5 to 110.4 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on January 6, 2026. The facility’s last fire drill was conducted on April 1, 2026. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Sharps and knives were secured in a drawer and chemicals were secured underneath the sink. All appliances were operational. Additional food supplies were stored in refrigerators and freezers in the garage. LPA toured resident rooms and rooms were clean, no odors were detected and all bedrooms had the required furnishings and linens. Cameras are in common hallways and the front door but there is no audio. Bathrooms had grab bars and non-skid mats and were clean. (Continued on LIC 809-C) (Continued from LIC 809) LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. There are three First Aid Kits, with a manual, with all the required elements and No Smoking signage was throughout the facility. LPA toured the exterior of the property and all exterior gates are unlocked alarmed and self-latching. There is ample space for activities outdoors and a large shaded seating area was observed. There are no hazards or obstruction of pathways. The PUB 475 poster and Long Term Care Ombudsman posters were displayed in a prominent area. The facility has current liability insurance. LPA reviewed two of two staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on August 3, 2027. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Administrator Florica Gheorghe and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Jun 16, 2026

Type of visit: Required - 1 Year

On June 11, 2025, at 3:15pm, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Administrator (AD) Florica Gheorghe. AD Florica Gheorghe has an administrator certificate with an expiration date of August 3, 2026. The facility is licensed to operate for six (6) non-ambulatory and a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) bedrooms, three (3) bathrooms, living area, dining area, kitchen, an attached garage, and outside covered patio area. There are four residents on census, all present during today’s visit. LPA obtained copies of pertinent documents, including facility records, clients/staff rosters and Personnel Record (LIC500). During the visit, LPA Bentley toured the interior and exterior of the physical plant with AD Gheorghe and the following was observed: There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperatures in three bathrooms measured 103.2 degrees F and 119.0 degrees F. A comfortable temperature of 74 degrees F was maintained throughout the facility. There is a two car garage with two refrigerators and additional supply of perishable items. The washer and dryer were observed to be in working condition. Facility has emergency food supply and water supply. The backyard was clean and free of clutter and debris. A shaded patio area with tables and chairs was observed. No deficiencies were cited at the time of the visit.An exit interview was conducted and a copy of this report was provided to Administrator Florica Gheorghe.the state’s words, verbatim · CDSS document, Jun 11, 2025

Allegation investigated: Uncleared adults providing care to residents

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 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.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 22-AS-20241008082533

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Oct 11, 2024

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: 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.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: 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.

Allegation investigated: Staff shoved food at residents. Staff yells at residents. Staff doesn't treat residents with dignity and respect.

Regarding the complaint allegation: Staff shoved food at residents 5 of 8 individuals interviewed including facility resident denied the complaint allegation. Multiple residents interviewed denied the allegation, and also denied seeing staff shove food at any resident. One of the residents who’s assisted with feeding denied the allegation and said staff treat them well. Regarding the complaint allegation: Staff yells at residents 5 of 8 individuals interviewed including facility residents denied the complaint allegation. One of the residents stated, some of the residents are hard of hearing so staff might raise their voice, but the resident denied staff yell at them or any other residents. Another resident stated, staff may elevate their voice, but the resident said they would not call it yelling. Continued on LIC9099C Unsubstantiated Regarding the complaint allegation: Staff doesn't treat residents with dignity and respect. 5 of 8 individuals interviewed including facility residents denied the complaint allegation. Multiple residents said they are treated well by the staff. One resident said the Unidentified Individual 1 (UI1) is an angel when the resident was asked how they (UI1) treat them. Based on the information gathered during the investigation through interviews, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 22-AS-20241008082533

Allegation investigated: 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

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 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.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 22-AS-20240830154950

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Sep 18, 2024

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: 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.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(c) · Plan of correction due date: Sep 18, 2024

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: 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.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

Type of visit: Case Management - Annual Continuation

On June 17, 2024, at 8:00am Licensing Program Analyst (LPA) Edward Kim arrived to complete the required 1-year annual visit that was started June 12, 2024. LPA Kim was greeted and granted entry by Administrator (AD) Florica Gheorghe. During the visit, LPA conducted a full audit of all staff files, resident files, and all resident medications. LPA Kim conducted 2 staff interviews and 2 resident interviews. No deficiencies cited during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Florica Gheorghe..the state’s words, verbatim · CDSS document, Jun 17, 2024

Type of visit: Required - 1 Year

On June 12, 2024 at 3:25pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Florica Gheorghe and explained the purpose of the visit. The facility is licensed to operate for six (6) non-ambulatory and a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) bedrooms, three (3) bathrooms, living area, dining area, kitchen, an attached garage, and outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant with AD Gheorghe. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4 and Staff room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature of 77 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency supplies were in order and complete. The facility has two (2) fire extinguisher that was charged and serviced on March 1, 2024. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-519-3082) remains available. First aid kit was in order and had all the necessary elements. Evaluation Report Continues on LIC 809-C Due to time constraint a continuation of this inspection will be conducted at a later date. LPA Kim will conduct record review for staff and resident, staff and resident interviews, and medication review at a later date. An exit interview was conducted, and a copy of this report was provided to Administrator Florica Gheorghe.the state’s words, verbatim · CDSS document, Jun 12, 2024