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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320024
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:59:05 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, 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
10/11/2024 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20241011142515
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: 3DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator - Angelique GradneyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident developed a Stage 3 pressure injury while in care.
INVESTIGATION FINDINGS:
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On 01/23/2025, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced subsequent complaint visit at this facility. CCLD staff met with Administrator, Angelique Gradney. CCLD staff explained the purpose of this visit.

The investigation consisted of the following: On 10/14/2024, CCLD staff initiated the complaint investigation and requested: Personnel Report LIC 500, residents service records which included: Physicians Reports, Identification and Emergency Information’s, Admission Agreements, Resident Appraisals, and Medication Administration Records and a tour of the facility was conducted. On 10/17/2024 to 12/20/2024, CCLD staff: interviewed facility residents, facility staff, witnesses (Home Health staff, Physicians, Social Workers, Registered Nurses, etc.); and requested R1’s records from several agencies which included medical records. On 01/08/2024, CCLD staff submitted an Investigation Care Report of interviews conducted and records reviewed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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 4
Control Number 11-AS-20241011142515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 01/23/2025
NARRATIVE
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The investigation revealed the following: Regarding the allegation “Resident developed a Stage 3 pressure injury while in care”, it is being alleged that staff do not reposition Resident 1 (R1) as instructed by medical professionals which resulted to R1 developing prohibited health conditions. Records reviewed revealed the following: On 4/29/2024, R1’s Physicians Report does not mention pressure injuries or states “No” under “History of Skin or Breakdown.” On 05/01/2024, R1 was admitted to the facility; R1’s Preplacement Appraisal does not mention pressure injuries or history of skin breakdown; R1 was admitted to Home Health and was assessed by a Home Health Registered Nurse and noted no wounds and skin intact. On 05/03/2024, Home Health Record noted a sore on R1’s buttocks the Home Health nurse “instructed caregivers to reposition every 2 hours” and facility staff verbalized understanding; R1 was placed on an “individualized emergency plan.” Home Health Records indicate that Home Health nurses consistently advised facility staff to turn and reposition R1 every two hours, maintain skin clean and dry at all times, and advised them on the importance of movement and mobility for circulation, reduce prolonged exposure to pressure and facility staff (S1, S2, S3, and S4) “verbalized understanding or teachings and instructions.” between 05/03/2024 to 10/05/2024. Home Health Records indicated that on 06/25/2024, R1 developed stage 2 pressure injury to the buttock region and nurse provided staff with education on prevention with pressure wounds. Facility Records indicated that care was not being provided to residents between 8:00 PM to 7:00 AM seven days a week during the months of September 2024 and October 2024. On 09/04/2024, Home Health Records reveal that R1 acquired new wounds on inner leg, right foot heel, bruises to buttocks, and arms are swollen; Home Health Records describe R1 as having seven wounds. Hospital Medical Records indicated that on 10/08/2024, R1 was diagnosed with stage 3 pressure injury on left heel measuring 1.4cm and an unstageable pressure injury on his right heel, measuring 2x1.5x0.1cm. Interviews conducted revealed the following: On 10/17/2024, Four residents indicated that facility staff does not check in on them from 2:00 AM to 6:00 AM. One resident explains that staff tells them to request their needs before 7 PM because after 7 PM they will not assist. Staff 1 indicated that Home Health “Nurses advised them to reposition R1 every two hours.” Staff 2 indicated that “no one would reposition R1 overnight. S2 explained that “at that time, we don’t have a night shift.” Interviews with facility staff revealed that care is not being provided to residents between 8:00 PM to 7:00 AM seven days a week upon their hire dates in 2023 up until 10/14/2024.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20241011142515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 01/23/2025
NARRATIVE
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Interviews with Home Health staff indicated that facility caregivers were “instructed…to keep R1 clean and dry and to reposition R1 every two hours, “around the clock” and added that, “the pressure injury never fully resolved because R1 was not consistently repositioned or kept clean and dry.” On 10/09/2024, Registered Nurse-Wound Care Nurse saw R1 at the hospital and they explained “that incontinence causes MASD (Moisture-Associated Skin Damage) wounds and that not being turned/repositioned would contribute to pressure injuries.” Regarding the allegation “Resident developed a Stage 3 pressure injury while in care”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on records reviewed and interviews conducted in accordance with the California Code of Regulations, Title 22, please see LIC9099D. An immediate $500 Civil Penalty assessed, please see LIC421.

Enhanced Civil Penalty:
At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to the Administrator, Angelique Gradney.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20241011142515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2025
Section Cited
CCR
87411(a)
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Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided...facility require such additional staff for the provision of adequate services.
This has not been met as evidenced by:
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On 10/15/2024, Licensee provided facility with overnight staff.

The Administrator has agreed to create a plan to follow CCR 87411 Personnel Requirements regarding services necessary to meet the needs of residents who require
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Based on interviews and record review, the licensee did not have staff working between 8PM and 7AM to provide R1 with their care needs, which resulted in R1 developing a stage 3 pressure injury while in care.
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rotation every 2 hours and to follow Home Health instructions for residents in care.

Email plan to Socorro.Leandro@dss.ca.gov
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4