197607201-8-15-2023-11-AS-MVAO-CVEULZ-20230906154133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607201
Report Date: 05/25/2023
Date Signed: 08/15/2023 03:23:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/16/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20230516154114

FACILITY NAME:	GOLDEN CITY HOME CARE		FACILITY NUMBER:	197607201
ADMINISTRATOR:	ANTONIA DIONISIO		FACILITY TYPE:	740
ADDRESS:	2451 W. 230TH STREET		TELEPHONE:	(310) 325-1995
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 6	DATE:	05/25/2023
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Cielo Devera		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not adhering to the approved hospice waiver

INVESTIGATION FINDINGS:

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*** This amended Complaint Investigation Reports LIC9099 and LIC9099-C dated 08/11/2023 superseded the original LIC9099 and LIC9099-C reports dated 05/05/2023 ***
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on, Friday, August 11, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. On 05/25/2023 LPA Bunker met with House Manager Ronnie Coronacion and Assistant Administrator Rhoda Mabutas. On 08/11/2023 LPA Bunker met with staff Cielo Devera to sign the amended copies of the LIC9099 and LIC990-C. LPA Bunker explained the purpose of today's visit.
The investigation consisted of the following: LPA Bunker interviewed staff 1-2 (S1-S2) and residents 1-6 (R1-R6). LPA Bunker asked questions relevant to the nature of the complaint. S1-S2 stated the facility only has one (1) resident on hospice and the facility is approved for one hospice resident. LPA Bunker requested and reviewed the resident’s records. LPA Bunker interviewed residents 1-6 (R1-R6). R1 stated she was receiving hospice care. R2-R6 stated they were not on hospice. LPA Bunker requested copies of supporting documents. See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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 11-AS-20230516154114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CITY HOME CARE	FACILITY NUMBER: 197607201
	VISIT DATE: 05/25/2023

NARRATIVE

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Continued LIC9099-C page 2

Allegation: The facility is not adhering to the approved hospice waiver
Staff 1-2 (S1-S2) stated the facility staff is adhering to the approved hospice waiver. S1-S2 stated the facility is approved for one (1) hospice waiver. S1-S2 stated that the facility has a waiver for 1 terminally ill resident to receive care from a hospice agency, the licensee obtained an approved facility hospice care waiver from the Department. The hospice care services are only provided to 1 resident living at the facility. S1-S2 stated the facility does not have 5 residents on hospice care, the facility only has 1 resident in hospice. S1-S2 stated the facility currently has six (6) residents in placement and 1 resident in hospice. S1-S2 denied the allegation.

Investigation revealed the following:
Interviews were conducted with staff 1-2 (S1-S2) who stated the facility only has one (1) resident on hospice and has an approved hospice waiver for that resident. During today's visit, LPA Bunker only observed 1 hospice resident in placement. Resident records indicated only 1 resident was in hospice. LPA Bunker observed the facility license posted on the hallway wall that stated the facility is licensed to serve six (6) residents age 60 and above, five (5) non-ambulatory, 1 bedridden, and a hospice waiver approved for 1 resident. The licensee has obtained a facility hospice care waiver from the Department. R1 stated she is receiving hospice care. R2-R6 stated they are not receiving hospice care. R1-R6 stated they are happy living here and the staff takes good care of them. S1-S2 stated the allegations are false. Staff 1-2 (S1-S2) interviewed denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC 9099 and LIC9099-C, was provided to House Manager Ronnie Coronacion and Assistant Administrator Rhoda Mabutas.

There were no deficiencies cited. An exit interview was conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

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