198320383-7-24-2026-11-AS-PMAA-DWQS57-20260807133353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320383
Report Date: 07/24/2026
Date Signed: 07/24/2026 03:11:28 PM

Unsubstantiated

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
11/25/2025 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251125145553

FACILITY NAME:	GOLDEN SENIOR ASSISTED LIVING II		FACILITY NUMBER:	198320383
ADMINISTRATOR:	ESPINO, CHRISTIAN		FACILITY TYPE:	740
ADDRESS:	1644 W 222ND STREET		TELEPHONE:	(310) 783-0501
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 6	DATE:	07/24/2026
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Nicholas Bana		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff retained a resident who requires a higher level of care.
Staff did not address resident's change of condition.
Staff did not prevent resident from developing a pressure injury.
Staff are not meeting resident's medical needs.

INVESTIGATION FINDINGS:

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On 07/24/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA spoke with Administrator Assistant Rudolfo “Ninyo” Lozada and the purpose of the visit was explained.

Investigation consisted of the following: On 12/04/2025, LPA obtained Personnel Report (dated 10/16/25), Register of Residents (dated 10/25/25), R1 – R4’s Admission Agreement, Needs and Services Plan, Medication Administration Record (September 2025 – December 2025), Physician’s Report, and Incident Reports (date occurred 11/06/25 and 11/10/25). LPA interviewed Staff #1 – 3 and Residents #2 – 4. On 12/05/25, LPA received R1 – R4 Pre-appraisals, R1’s Cedars Sinai medical records (attestation signed 04/23/25), Los Angeles Community Hospital medical records (11/06/25 – 11/07/25, 11/12/25 - 11/13/25, Updated 11/21/25), Communication Responses, and Quality Home Health inquiry. Note: Resident #1 was not at the facility. Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

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-20251125145553

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 SENIOR ASSISTED LIVING II	FACILITY NUMBER: 198320383
	VISIT DATE: 07/24/2026

NARRATIVE

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Regarding the allegation, “Staff did not address resident's change of condition,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

Allegation: Staff did not prevent resident from developing a pressure injury.
It is being alleged that staff does not move or adjust Resident #1. Record review of R1’s Physician’s Report (07/03/25) revealed R1’s primary diagnosis necrotizing fasciitis, uses a wheelchair, and does not require continuous bed care. Record review of email correspondence (10/08/25-10/09/25) revealed S1 seeking home health or wound care services for R1. S1 indicated noticing redness on R1’s skin and would like a nurse to assess and provide preventative assistance. Review of Los Angeles Community Hospital (11/06/25) revealed R1 has a skin rash in sacral area and the plan was to consult a wound specialist. Review of Harbor UCLA Hospital Record (11/10/25) revealed R1 did not have rashes or lesions. Review of Los Angeles Community Hospital (11/13/25; updated 11/21/25) revealed R1 had a stage two pressure ulcer of sacral region. S2 indicated that upon admissions, R1 had a sore on R1’s back. It was cleaned, bandaged, and no longer there. S3 indicated upon admission, R1 had a rash. Interview with S2 – S3 indicated that R1 is repositioned every two – two ½ hours. S1 indicated R1 was bedbound around the last week of October. R1 could sit in a wheelchair but was always in bed. R1 could move left to right but was very tired from dialysis (three times per week). S1 indicated S1 looked for home health services for R1 but there was an issue with insurance. R1 was discharged from the facility on 11/16/25. R3 indicated R3 is able to reposition self. LPA observed R2 and R4 to be ambulatory.

Regarding the allegation, “Staff did not prevent resident from developing a pressure injury,” based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20251125145553

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 SENIOR ASSISTED LIVING II	FACILITY NUMBER: 198320383
	VISIT DATE: 07/24/2026

NARRATIVE

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Investigation revealed the following:
Allegation: Facility staff retained a resident who requires a higher level of care.
Regarding the allegation, “Facility staff retained a resident who requires a higher level of care,” it is alleged that staff does not have the ability to provide care and supervision appropriate to meet the needs of the residents. Record review revealed the following: R1’s Cedars-Sinai medical record (04/23/25) revealed R1 was at the hospital due to End-Stage Renal Disease (kidney failure). Admission Agreement revealed R1 was admitted into the facility on 07/03/25. Review of R1’s Physician’s Report (07/03/25) revealed R1’s secondary diagnosis as End-Stage Renal Disease, physical health status is good, weighed 132 pounds, and is able to feed self. Interviews revealed the following: three out of three staff interviews (S1 – S3) did not agree with the allegation. All three staff members indicated R1 receives dialysis services. S2 indicated R1 would vomit after dialysis and R1’s dialysis provider confirmed it was normal. S3 indicated R1 ate good but would vomit when full. S3 indicated R1 did not lose weight. Three out of three resident interviews indicated they do not require a higher level of care. R3 indicated a nurse visits to provide additional care services. R2 and R4 do not require additional care services and staff provide assistance with activities of daily living.

Regarding the allegation, “Facility staff retained a resident who requires a higher level of care.,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

Allegation: Staff did not address resident's change of condition.
Regarding the allegation, “Staff did not address resident's change of condition,” it is alleged, staff did not address changes in Residents appetite. Record review of R1’s Physician’s Report (07/03/25) revealed R1 weighed 132 pounds, is not on a special diet, and is able to feed self. Review of Los Angeles Community Hospital medical records (11/10/25) revealed R1 weighed (49 kg) 108 pounds, is underweight (BMI 16.9), and has severe protein-calorie malnutrition (BMI 16.9, poor intake, MST 3). Two out of two staff interviews (S2 – S3) indicated R1 ate good but vomited at times. S2 indicated that R1 has vomited after dialysis but the dialysis staff said it was normal. S1 indicated that R1’s health has not changed but R1 is agitated while at dialysis. S1 was instructed to call R1’s doctor but R1’s doctor said R1 was not on the list. R3 indicated staff will let the nurse know when they are not feeling well. Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20251125145553

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 SENIOR ASSISTED LIVING II	FACILITY NUMBER: 198320383
	VISIT DATE: 07/24/2026

NARRATIVE

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Allegation: Staff are not meeting resident's medical needs.
Regarding the allegation, “Staff are not meeting resident's medical needs,” it is being alleged that staff does not have equipment to check Resident #1’s blood sugar level, does not schedule doctor appointments, nor retrieve medication. Record review of Cedars Sinai (attestation signed 04/23/25) does not diagnosis R1 with diabetes. R1’s Physician’s Report (07/03/25) does not include a diabetes diagnosis nor does R1 have a special diet. It revealed R1 took medication for: antidepressant and smoking cessation, epilepsy, GERD, hypotension, schizophrenia, and anxiety. R1 also took vitamins. Medication Administration Record (September 2025 – November 2025)) revealed staff retrieved R1’s medication for: antidepressant and smoking cessation, epilepsy, GERD, hypotension, schizophrenia, and anxiety. Though R1 ran out of antidepressant and smoking cessation aid on 10/10/25 – 10/21/25. R1 ran out of GERD medication on 10/15/25 – 10/21/25. R1 ran out of anxiety and depression medication on 10/15/25 – 10/21/25. R1 ran out of schizophrenia medication on 10/11/25 – 10/21/25. Screenshot (10/21/25) revealed R1’s medication was delivered to the facility. Review of Los Angeles Community Hospital (11/06/25) revealed R1 is check A1c at bedtime with regular insulin sliding scale low-dose. Review of Los Angeles Community Hospital (11/13/25) revealed R1 was transferred from Harbor UCLA Hospital for further management of symptomatic hypoglycemia. According to the transferring facility, the patient was found to have low blood glucose levels, associated with altered mental status and generalized weakness. Interview with S1 indicated R1 is not a diabetic so staff did not check R1’s blood sugar but blood pressure. S1 attempted to schedule doctor appointments but R1 had insurance issues. S1 indicated R1 had insurance problems and it didn’t cover the medication and the only option was to send R1 to the hospital to retrieve medication. The facility staff sent R1 to Torrance Memorial Hospital on 10/10/25 and R1 stayed there for about seven days. In addition, S1 indicated R1 would refused some medication after dialysis. S3 indicated S3 did not check R1’s blood sugar. R3 indicated R3 is able to do own injections, has enough supplies, and goes to Veterans Affairs for doctor appointments. R4 indicated family assists with medical appointments and transportation. R2 does not currently have a doctor and is new to the facility. Regarding the allegation, “Staff are not meeting resident's medical needs,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

No deficiencies cited. An exit interview was conducted and a copy of this report was emailed to the Assistant Administrator due to technical difficulties.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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