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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610238
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:36:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230222103008
FACILITY NAME:GOLDEN YEARS HOMEFACILITY NUMBER:
197610238
ADMINISTRATOR:BARRERA, OSCAR & MARINAFACILITY TYPE:
740
ADDRESS:44315 CASA NOVA DRTELEPHONE:
(661) 206-8026
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 3DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Oscar BarreraTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Resident has an unexplained bruise
Staff are not reporting resident falls resulting in a bruise

INVESTIGATION FINDINGS:
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On 3/01/2023 at 12:46 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct a subsequent complaint visit for the allegations mentioned above. LPA was granted entry into the facility by staff #1 (S1). LPA met with Licensee and explained the reason for the visit.

From 12:50 p.m. to 1:00 p.m. LPA interviewed resident's #1 (R1) hospice nurse. According to hospice nurse R1 is not on blood thinners, however R1 has a history of being combative with themselves. Nurse states, bruise is likely the result of bedrails on R1's bed.

Allegation #1:Resident has an unexplained bruise
It is alleged R1 has a bruise on right shoulder and no one knows how R1 received the bruise. LPA's initial interview with Licensee and staff revealed facility was aware of a bruise on R1's arm but not specifically on their shoulder. LPA observed a bruise on R1's inner right arm by elbow not on their shoulder. (Continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 2
Control Number 31-AS-20230222103008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN YEARS HOME
FACILITY NUMBER: 197610238
VISIT DATE: 03/01/2023
NARRATIVE
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Licensee stated R1 tends to hit themselves on bed rails and so the facility now places pillows on either side of R1 to prevent injury. LPA's interview with R1's responsible party revealed they were not aware of bruise but had been away for two weeks and is not sure if facility had attempted to contact them. Furthermore responsible party corroborates, R1 is prone to behavior that may cause injury to themselves. Based on the information obtained through interviews, and document review this allegation is deemed Unsubstantiated at this time.

Allegation #2: Staff are not reporting resident falls resulting in a bruise

It is alleged resident #2 (R2) has fallen many times resulting in a bruise on her face and was not reported. During initial investigation on 02/27/2023 interview with Licensee revealed R2 has not had any falls while at the facility. Interview with responsible party for R2 on 02/27/2023 reveals R2 has a history of falling before R2 was admitted to this facility. According to R2's responsible party they have not seen a bruise on R2's face and they visit R2 on a regular bases. LPA review of incident reports sent to Community Care Licensing Division (CCLD) by facility and no incident reports for R2 for found. LPA did not observe any bruising on R2's face. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
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