<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607206
Report Date: 02/11/2023
Date Signed: 02/11/2023 03:21:03 PM

Substantiated


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
12/22/2020 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20201222113312
FACILITY NAME:GOLDEN CARE LIVING, INC.FACILITY NUMBER:
197607206
ADMINISTRATOR:ANGELIQUE S. GRADNEYFACILITY TYPE:
740
ADDRESS:2052 REDONDELA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
02/11/2023
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Catherine Espino TIME COMPLETED:
12:31 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiple pressure injuries while in care.
Staff failed to meet the resident's needs.
Staff failed to meet resident's incontinence needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit at this facility. LPA was greeted by care staff (S2) Rachel Lugtu. LPA conducted a risk assessment prior to entering the facility. Lugtu informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. Lugtu contacted administrator (S1) Catherine Espino by phone and LPA explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Jose Calderon conducted the 10-day tele-visit (via FaceTime) on 12/24/2020 approximately 4:45 p.m. with Administrator Angelique Gradney. LPA toured the facility (via FaceTime) with Administrator and requested copies of the following documents: facility staff and resident rosters; Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, medical records (to include hospital records), Medication Administration Records (July 2021), and Unusual Incident/Injury Report for Resident #1. A separate investigation was conducted by the Department of Social Services, Investigator Jose Santana that included a review of hospital medical records, interview with witnesses, facility staff, and medical services staff. (Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023
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 6
Control Number 11-AS-20201222113312
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 CARE LIVING, INC.
FACILITY NUMBER: 197607206
VISIT DATE: 02/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:

Regarding Allegation #1: this investigation revealed that Resident #1 was admitted to the hospital on 08/21/20 with an open wound to the right hip – measuring: 8cm x 0.2cm. Upon discharge on 08/24/20, home health services were obtained, effective 08/25/20. Despite regular wound care by home health nurses, Resident #1’s right-hip wound worsened over time; and, the wounds increased in number to include pressure injuries on their bilateral heels. On Resident #1’s return from hospitalization on 08/25/20, there was an order for the fungal rash: cleanse with soap and water, pat dry, apply Miconazole Topical 2% and Calmoseptine, and leave open to air. Although, it is possible that Resident #1’s scratching of their wounds and fungal infection prevented the pressure injuries from resolving, it is more likely that unattended moisture and failure to reposition the resident every two (2) hours at night contributed to the progression of the pressure injuries. Witness #4 (Home Health Care Manager) believes the lack of frequent repositioning and keeping Resident #1 dry overnight was the primary reason why the right hip progressed from Stage II pressure injury at the beginning of home health services to an Unstageable pressure injury – measuring: 4.6cm x 1.8cm x 0.2cm by 09/14/20. As of 01/20/21, the right hip pressure injury remained Unstageable. The facility retained Resident #1; and, the resident’s pressure injury was over a Stage II, a prohibited health condition.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained multiple pressure injuries while in care is found to be SUBSTANTIATED.



Regarding Allegation #2: this investigation revealed that the Home Health Agency skilled nurse was aware that Resident #1 was not being repositioned overnight because there was no nighttime caregiver available. Despite regular wound care by the home health nurses, Resident #1’s right-hip wound worsened over time; and, the Home Health Agency skilled nurse recommended that Resident #1 be transferred to a higher level of care. This requirement is not met as evidenced by: Lack of frequent repositioning every two (2) hours and keeping Resident #1 dry overnight was the primary reason why the right hip progressed from a Stage II pressure injury to Unstageable.

Evaluation Report continues LIC-9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20201222113312
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 CARE LIVING, INC.
FACILITY NUMBER: 197607206
VISIT DATE: 02/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of LEVEL OF CARE: Staff failed to meet the resident’s needs is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D).

Regarding Allegation #3: this investigation revealed that the facility hired live-in caregivers with no designated awake night staff. Residents who required overnight care (i.e., incontinence care and pressure injury prevention, such as, turning and repositioning every two (2) hours are not always receiving the care they need. In addition, Home Health Agency skilled nurse reiterated instructions for facility caregivers to turn and reposition Resident #1 every two (2) hours, to change diaper promptly after incontinence episodes. Based on interviews conducted, the majority staff corroborated that they are not paid to work overnight; therefore, turning and repositioning Resident #1 at 9:00 p.m., 11:00 p.m., 1:00 a.m., and 3:00 a.m. was not being done. Staff #2 (Lead Caregiver/House Manager) admitted that Resident #1 was not always turned and repositioned every two (2) hours overnight, but maybe at 9:00 p.m. and 3:00 a.m. This requirement is not met as evidenced by: There is no overnight staff to assist residents with personal hygiene (incontinence care) needs.

Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of LEVEL OF CARE: Staff failed to meet resident’s incontinence needs is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D).

****Civil penalty is assessed.***

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator Catherine Espino.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20201222113312
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 CARE LIVING, INC.
FACILITY NUMBER: 197607206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2023
Section Cited
CCR
87615(a)(1)
1
2
3
4
5
6
7
Section 87615(a)(1) Prohibited Health Conditions: Persons who require health services or have a health condition including... shall not be... retained in a... care facililty sores (dermal ulcers).

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator shall read Title 22, Section "Prohibited Health Conditions"...send a written statement to CCLD that they will ensure to stay in constant communication with medical professional(s) and if the resident's medical condition elevates; meaning they require a higher level of care, they will ensure the resident is relocated to
8
9
10
11
12
13
14
Resident #1 was diagnosed with Unstageable and Stage 3 dermal ulcers on 08/21/22 and Administrator retained Resident #1 at the facility following Resident #1’s discharge from the hospital on 08/24/22 with “Unstageable” and “Stage III” wounds. This violation poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
a skilled-nursing facility (SNF) or hospital... Civil penalties are assessed in the amount of Five-hundred Dollars ($500) for retaining Resident #1 with a prohibited health condition. This plan is due to CCLD/El Segundo ASC Office by POC date of 02/12/23.
Type A
02/12/2023
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator shall read Title 22, Section 87466 “Observation of the Resident” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 02/12/23.
8
9
10
11
12
13
14
Home Health Agency skilled nurse was aware that Resident #1 was not being repositioned overnight because there was no nighttime caregiver available to do so and recommended Resident #1 to a higher level of care. This violation poses an immediate health, safety or personal rights risk to persons in care.

8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20201222113312
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 CARE LIVING, INC.
FACILITY NUMBER: 197607206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2023
Section Cited
CCR
87405(a)-(C)
1
2
3
4
5
6
7
Section 87405(a)–(c) Administrator - Qualifications and Duties:(a) All
Facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom
from other responsibilities and shall be on the premises a sufficient number of hours... to permit adequate attention to the management and administration of the facility as specified in this...have qualifications adequate to be responsible and accountable for management and administration... (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (c) Failure to comply with all licensing requirements... may constitute cause for revocation of the
license of the facility.
1
2
3
4
5
6
7
Licensee/Administrator shall read Title 22, Section 87405(a)–(c) “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 02/27/23
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Resident #1 was transported to the hospital on 08/21/21 and hospital staff noted Stage II pressure injury to their right hip. By November 2020, Resident #1’s right hip developed from a Stage II to Unstageable/Stage III. This violation poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20201222113312
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 CARE LIVING, INC.
FACILITY NUMBER: 197607206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2023
Section Cited
CCR
87609(C)
1
2
3
4
5
6
7
87609(c) Allowable Health Conditions and the Use of Home Health Agencies: (c) The use of home health agencies to care for a resident’s medical condition(s) does not expand the scope of care and supervision that the licensee is required to provide.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator shall read Title 22, Section 87609(c) "Allowable Health Conditions" and send a written statement to CCLD that licensee and home health agency agree (in writing) on the responsibilities of the home health agency and those of the licensee in caring for the resident’s medical condition.
8
9
10
11
12
13
14
Home Health Agency skilled nurse provided training to facility staff on how to turn and reposition resident every two (2) hours; of which, facility staff failed to turn and reposition Resident #1 every two (2) hours over night. This violation poses an immediatel health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
This plan due to CCLD/El Segundo ASC Office by POC date of 02/12/23.
Type B
02/27/2023
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
Section 87411(a) Personnel Requirements – General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff... ensure provision of ...care as required in Section 87608, Postural Supports.
1
2
3
4
5
6
7
Licensee/Administrator shall read Title 22, Section 87411(a) “Personnel Requirements – General” and send a written statement to CCLD that licensee has read and understands that facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident’s needs.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: There is no overnight staff to assist residents with personal hygiene (incontinence care) needs. This violation poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
This plan due to CCLD/El Segundo ASC Office by POC date of 02/27/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6