198601924-6-9-2020-11-AS-AJKK-BR2KJV-20200629075720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601924
Report Date: 06/09/2020
Date Signed: 06/09/2020 05:45:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2020 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20200129151010

FACILITY NAME:	GOLDEN CARE LIVING II		FACILITY NUMBER:	198601924
ADMINISTRATOR:	ANGELIQUE GRADNEY		FACILITY TYPE:	740
ADDRESS:	1854 EL REY ROAD		TELEPHONE:	(310) 989-1941
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	6	CENSUS: 4	DATE:	06/09/2020
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Angelique Gradney		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident developed dehydration while in care
Resident sustained a stage 2 pressure injury while in care.
Facility staff left resident in soiled clothing/wet diaper for an extended period of time.

INVESTIGATION FINDINGS:

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On 6/9/2020 at 9:30 am, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit to this facility to deliver findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Angelique Gradney, the Licensee and Administrator.

LPA Montoya explained the purpose of this video call to Angelique Gradney/Licensee.

Investigation consisted of the following: Interviews with staff, residents, R#1’s family, and Home Health staff. R#1’s medical records including hospital and home health records were obtained and reviewed. Facility staff roster and staff schedules, resident’s medication list and photos of the facility were also obtained.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200129151010

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING II	FACILITY NUMBER: 198601924
	VISIT DATE: 06/09/2020

NARRATIVE

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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, therefore the allegation is UNSUBSTANTIATED.

LPA advised Angelique Gradney to sign the report, scan and email it back to Lourdes.montoya@dss.ca.gov by end of business day today, June 9, 2020.

No deficiencies were cited. An exit interview was conducted. An electronic copy of this report was emailed to Licensee, Angelique Gradney, for her signature.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200129151010

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING II	FACILITY NUMBER: 198601924
	VISIT DATE: 06/09/2020

NARRATIVE

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Investigation Revealed:

Allegation: Resident developed dehydration while in care” and “Resident sustained a stage 2 pressure injury while in care."

The Department conducted interviews with staff and residents from this facility. Interviews were also conducted with R1’s family and Home Health staff and there’s no evidence to corroborate the allegation mentioned above. There’s no evidence of neglect in care that resulted to pressure injury or lack of supervision resulting in resident’s hospitalization due to dehydration. Based on interviews with R1’s primary caregivers, there is no evidence of neglect or lack in care identified or reported. Based on interview with resident R2, resident had expressed that she has been a resident of this facility for over a year and she described her experience at this facility as a happy one and she observed that staff were attentive to R1's needs and services. Other residents were unable to participate with the interview due to their health conditions. R#1's home health medical and facility records were obtained and reviewed. Based on the information and evidences obtained, there’s no proof of negligence in which would account for the physical health, mental health, safety or welfare of R1’s care at this licensed facility.

Allegation: Facility staff left resident in soiled clothing/wet diaper for an extended period of time.

The department conducted interviews with staff (S1 and S2), residents (R2 and R4), and R1's family member and there 's no evidence to corroborate the allegation mentioned above. R3 was not able to participate in the interview because she was not willing to talk and there was no available Spanish interpreter. R5 was not able to participate in the interview because she was sleeping. R1's appraisal, physician's report and Home Health records were reviewed and there's no proof of negligence in which would account for the physical health, mental health, safety or welfare or R1's care at this licensed facility.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident developed dehydration while in care”, “Resident sustained a stage 2 pressure injury while in care" and "Facility staff left resident soiled clothing/wet diaper for an extended period of time".

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

LIC9099 (FAS) - (06/04)

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