079201163-5-3-2024-15-AS-YFLS-D7GSAT-20240724134252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201163
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:52:52 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2024 and conducted by Evaluator Alona Gomez

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240228151212

FACILITY NAME:	GOLDEN HILL HOMES, INC.		FACILITY NUMBER:	079201163
ADMINISTRATOR:	ANSARI, FATHMA		FACILITY TYPE:	740
ADDRESS:	9474 ALCOSTA BLVD		TELEPHONE:	(949) 278-8332
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 6	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Administrator, Fathma Ansari		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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On 5/3/2024 at 12:50 PM, Licensing Program Analyst (LPA), A. Gomez arrived unannounced to deliver complaint findings for the allegations above. LPA met with Administrator, Fathma Ansari and explained the reason for the visit.

Allegation: Questionable Death

On 2/28/2024, The Department received a complaint regarding the questionable death of R1. During the course of the investigation, the Department obtained and reviewed R1’s records including but not limited to: R1’s admission agreement, physician’s report, care plan, hospice notes, medication log, incident reports, and death certificate.

Report Continues on LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240228151212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLDEN HILL HOMES, INC.	FACILITY NUMBER: 079201163
	VISIT DATE: 05/03/2024

NARRATIVE

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R1 was admitted to the facility on 12/26/2023 on hospice care with Hope Hospice. R1 was recertified for hospice on 12/6/2023 with life expectancy of six months or less due to terminal diagnosis and co-morbidities. Physicians Orders for Life-Sustaining Treatment (POLST) dated 4/17/2023 was marked as do not resuscitate (DNR) by W1 and hospice care plan dated 12/26/2023 has advanced directives marked as DNR, no tube feeding, no transfer to acute hospital, and no lab work or x-rays without Hope hospice approval.

On 2/18/2024 unusual incident report indicated R1 was transferred from the facility to San Ramon Regional Medical Center via paramedics for agitation and restlessness. Facility staff S1 contacted Hope Hospice to inform of transfer despite staff relaying that R1 was on hospice. Hospice witness W2, contacted the attending physician and R1 was transferred back to the facility. R1 passed away on 2/23/2024.

The Department obtained certificate of death from Contra Costa County for R1 listing the immediate cause of death as cardiopulmonary arrest and underlying causes protein calorie malnutrition, failure to thrive, and Alzheimer’s dementia. Other significant conditions that contributed to R1’s death were listed as colon cancer with colostomy and atrial fibrillation. There are no questionable circumstances surrounding R1’s death.

This agency has investigated the complaint alleging Questionable Death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

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