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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201210
Report Date: 11/03/2025
Date Signed: 11/03/2025 03:09:29 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, 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
09/30/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250930090310
FACILITY NAME:GOLDEN STATE CARE HOME, INCFACILITY NUMBER:
079201210
ADMINISTRATOR:GONZALEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:4541 PAMPAS CIRCLETELEPHONE:
(925) 628-9912
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:4CENSUS: 4DATE:
11/03/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:MIchelle Gonzalez, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff inappropriately spoke to resident
Staff do not provide a safe environment for resident
INVESTIGATION FINDINGS:
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On 11/03/25 at 1:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit and met with administrator (ADM). LPA explained the purpose of the visit with staff (ADM). LPA delivered investigation findings to ADM.

During investigation, LPA obtained the following documents from administrator – Personnel record, Clients’ roster, pre-placement appraisal report, admission agreement, physician’s report, IPP plans, hospital notes, After visit summary reports, functional assessments, Notification of dangerous propensities, conservator paperwork, incident reports.

Continued on next page, LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
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 15-AS-20250930090310
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLDEN STATE CARE HOME, INC
FACILITY NUMBER: 079201210
VISIT DATE: 11/03/2025
NARRATIVE
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Allegation: Staff inappropriately spoke to resident
Finding: Unsubtantiated
During investigation, LPA interviewed reporting party (RP), clients (C1, C2), staff (ADM, S1) and reviewed C1’s documents. C1 stated staff never spoke to her inappropriately at any time. C1 stated staff constantly reminded her to be careful with her credit account and not let anyone use it for their own purchases. C1 confirmed with LPA that she had an incident on April 2025 where she had a verbal and physical altercation with C2 because she let her use her credit account with an agreement that C2 would pay her monthly until the bill is paid off. C2 never paid her back. Staff denied speaking inappropriately with any client in care. During unannounced visits on 08/30/24, 09/06/24 and 10/09/25, LPA observed staff did not speak inappropriately to clients in care. Clients (C1, C2, C3 C4) were observed comfortable in their surroundings and relaxed with staff assisting them with their meals, doctors’ appointments, medications and purchases. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff inappropriately spoke to resident is unsubstantiated.

Allegation: Staff do not provide a safe environment for resident


Finding: Unsubstantiated
During investigation, LPA interviewed reporting party (RP), staff (ADM, S1), clients(C1, C2) and reviewed C1’s documents. C1 and C2 both confirmed with LPA that they feel safe living at the facility. C1 stated she shares a bedroom with another client (C3) whom she gets along with and does not have any verbal or physical incidents. C1 stated she had a verbal and physical incident with another client (C2) who resides in her own private bedroom. C1 stated this incident happened on April 2025 when C2 overheard her talking about her to a friend on the phone when her bedroom door was open. C2 confronted C1 and hit her on the head because she felt disrespected. C1 stated staff redirected them, assisted C1 by calling police and 911 for evaluation and treatment. Staff reminded both clients about not allowing others to use their credit accounts to purchase items. During unannounced visits on 08/30/24, 09/06/24 and 10/09/25, LPA observed clients (C1, C2, C3, C4) comfortable in their surroundings and relaxed with staff assisting them with their meals, scheduled appointments and medications. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not provide a safe environment for resident is unsubstantiated.

Continued on next page, LIC 9099-C pg1

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
LIC9099 (FAS) - (06/04)
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