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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320024
Report Date: 01/06/2024
Date Signed: 01/06/2024 12:02:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20230106110553
FACILITY NAME:GOLDEN CARE LIVING IIIFACILITY NUMBER:
198320024
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1308 HICKORY AVETELEPHONE:
(310) 787-8369
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
01/06/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jeremy Nabres/CaregiverTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/6/2024, Licensing Program Analyst (LPAs) Alfonso Iniguez conducted a subsequent complaint visit at this facility to deliver the complaint investigation findings. LPA met with the Jeremy Nebres/Caregiver, who assisted with the visit. The purpose of the visit was explained.

The investigation consisted of the following: On 1/9/2023, LPA Montoya conducted a tour of the facility. LPA interviewed staff and witnesses. LPA’s attempt to interview all five residents was unsuccessful. LPA obtained copies of Staff Roster (LIC 500), Register of Facility Clients/Residents (LIC 9020) and resident’s (R1) Admission Agreement, Physician’s Report, Preplacement Appraisal, and Needs and Services Plan. During this visit, LPA did not observe R1’s Medication Administration Records and hospice referral order.

Report continued in LIC 9099C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
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-20230106110553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 01/06/2024
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:

Allegation: Staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician

Based on records review, Admission Agreement indicates Resident #1 (R1) was admitted to the facility on 12/29/2022. A hospice referral for R1 from SCAN Health Plan with Healing Care Hospice was dated 12/30/2022.

It was alleged that staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician. On 1/9/2023 from 11:00 am – 1:55 pm, LPA Lourdes Montoya conducted interviews with four out of four staff (S1-S4). LPA attempted to interview five out of five residents (R2-R6). Two out of five residents were sleeping, two out of five residents refused the interview, and one out of five residents was unable to maintain a conversation. R1 was transferred to another facility and LPA was unable to obtain statements from R1 during the visit.

Interviews with six witnesses (W1-W6) disclosed that Healing Care Hospice agency was the selected and preferred hospice agency to provide hospice care services to R1. Two out of six witnesses revealed the visiting nurse from Healing Care Hospice agency attempted to visit and assess R1 on 12/30/2022 around 6:00 pm, but facility staff denied the nurse an entry to the facility. W5 revealed R1 was transferred to another facility on 1/5/2023 due to the facility’s refusal to use R1’s preferred and contracted hospice agency.

Based on interviews conducted, two out of four staff (S3-S4) claimed they were confused about who is supposed to provide hospice care to R1. Both staff stated Global Hospice delivered a hospital bed, comfort kit, oxygen tank, and bedside table to the facility for R1 but another hospice agency (Healing Care Hospice agency) attempted to assess R1 on 12/30/2022 and the hospice nurse was denied entry. Two out of four staff (S1-S2) claimed there was no doctor’s referral for Healing Hospice Care agency to provide hospice care to R1. They also claimed Healing Care Hospice Nurse was not denied entry on 12/30/22 instead the visit was only placed on hold due to a confusion which hospice agency, between Global Hospice and Healing Care Hospice, was selected by R1’s family.

Report continued in LIC 9099C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20230106110553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 01/06/2024
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 LPA’s observation on 1/9/2023, a hospice comfort kit stored in the medication cabinet with R1’s name of the label was provided by Global Hospice Agency but there was no doctor’s referral for Global Hospice Agency. LPA also observed a hospital bed in the front patio. Per interview with a staff (S3), the hospital bed in the front patio was provided by Global Hospice for R1’s use. Based on information gathered, there is sufficient evidence to prove that staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician.

Based on the department’s observations, records review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 is cited on the attached LIC 9099D.

Exit interview was conducted and Appeal Rights was discussed with Jeremy Nabres/ Caregiver. A hard copy of the report and Appeal Rights were provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20230106110553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
CCR
87468.1(a)(16)
1
2
3
4
5
6
7
 87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(16) To receive or reject medical care or other services. This was not met as evidenced by:
1
2
3
4
5
6
7
The administrator shall review Section 87468.1 of Title 22 and shall self-certify understanding of this provision. Administrator shall conduct in-service training to staff about resident’s personal rights indicated in this section of Title 22. Administrator shall submit proof of corrections to CCLD by faxing to 424-544-1016 by the POC due date.

8
9
10
11
12
13
14
Based on interviews with six witnesses (W1-W6), it was revealed that Healing Care Hospice agency was the selected and preferred hospice agency to provide hospice care services to R1. Two out of six witnesses revealed the visiting nurse from Healing Care Hospice agency attempted to visit and assess R1 on 12/30/2022 around 6:00 pm, but facility staff denied the nurse an entry to the facility. W5 revealed R1 was transferred to another facility on 1/5/2023 due to the facility’s refusal to use R1’s preferred and contracted hospice agency. This poses an immediate risk to health, safety and/or personal rights to residents 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20230106110553

FACILITY NAME:GOLDEN CARE LIVING IIIFACILITY NUMBER:
198320024
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1308 HICKORY AVETELEPHONE:
(310) 787-8369
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
01/06/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jeremy Nabres/CaregiverTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff refused to refund resident's unused rent.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/6/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a subsequent complaint visit at this facility to deliver the complaint investigation findings. LPA met with Jeremy Nabres/Caregiver, who assisted with the visit. The purpose of the visit was explained.

The investigation consisted of the following: On 1/9/2023, LPA Montoya conducted a tour of the facility. LPA interviewed staff and witnesses. LPA’s attempt to interview all five residents was unsuccessful. LPA obtained copies of Staff Roster (LIC 500), Register of Facility Clients/Residents (LIC 9020) and resident’s (R1) Admission Agreement, Physician’s Report, Preplacement Appraisal, and Needs and Services Plan. During this visit, LPA did not observe R1’s Medication Administration Records and hospice referral order.

Report continued in LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20230106110553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 01/06/2024
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:

Allegation: Facility staff refused to refund resident's unused rent payment

Based on records review, Admission Agreement indicates Resident #1 (R1) was admitted to the facility on 12/29/2022. R1 moved out and transferred to another facility on 12/5/2023.
It was alleged that facility staff refused to refund resident's unused rent payment. On 1/9/2023 from 11:00 am – 1:55 pm, LPA Lourdes Montoya conducted interviews with four out of four staff (S1-S4). LPA attempted to interview five out of five residents (R2-R6). Two out of five residents were sleeping, two out of five residents refused the interview, and one out of five residents was unable to maintain a conversation. R1 was transferred to another facility and LPA was unable to obtain statements from R1 during the visit.

The department reviewed Resident’s (R1) service records. Based on records review, the Admission Agreement indicates “Resident is required to pay a full amount of Non-refundable Board and Care fee upon admission”, and “A thirty days written notice of intent to vacate is required or will be charged a full month pay on the following month or until all belongings are removed from the facility”. Based on interviews conducted, S1 stated the facility is willing to refund a prorated amount based on the days R1 resided in the facility. Based on LPA’s follow-up telephone interview with S1 on 1/10/22, S1 stated a refund letter for R1 was generated and a copy will be provided to the department. LPA received and reviewed the refund letter which indicates the facility has refunded R1 a prorated amount of $4600.00 of which $1400.00 was charged for her seven days of stay at the facility. Based on the information gathered, there is insufficient evidence to corroborate the above allegation.


Based on the department’s observations, interviews and records review, the preponderance of evidence standard has not been met therefore the above allegation, “Facility staff refused to refund resident's unused rent payment” is found to be UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was provided to Jeremy Nabres/Caregiver

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6