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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601924
Report Date: 07/07/2022
Date Signed: 07/10/2022 03:33:10 PM

Substantiated


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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2019 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20191119134759
FACILITY NAME:GOLDEN CARE LIVING IIFACILITY NUMBER:
198601924
ADMINISTRATOR:ANGELIQUE GRADNEYFACILITY TYPE:
740
ADDRESS:1854 EL REY ROADTELEPHONE:
(310) 989-1941
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 4DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Catherine EspinoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident developed multiple pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lourdes Montoya made an unannounced subsequent visit to the facility to deliver a complaint finding of the above allegation. Upon arrival, LPA called the facility to conduct a risk assessment. LPA spoke with Administrator Angelique Gradney, who confirmed the facility is Covid-19 free. LPA met with Caregiver Bertin Okezie who assisted with the visit. Staff Catherine Espino (Assistant to the Administrator) arrived later and joined the visit.The purpose of this visit was explained.

The investigation consisted of the following: On 11/19/2019, LPA Lourdes Montoya conducted a 24-hour complaint visit. During this visit, LPA obtained the Register of Facility Residents, Staff Roster, Administrator's Certificate, and Resident #1’s service records (Identification and Emergency Information, Admission Agreements, Preplacement Appraisal Information, Appraisal/Needs and Services Plan, Resident Personal Property and Valuables, Consent forms, Physician's Reports).

REPORT CONTINUED IN LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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 5
Control Number 11-AS-20191119134759
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
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING II
FACILITY NUMBER: 198601924
VISIT DATE: 07/07/2022
NARRATIVE
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A separate investigation was conducted by the Department of Social Services Investigations Branch (IB) Investigator Jose Santana which included reviews of Resident #1’s (R1) service records, hospital records from Providence Little Company of Mary Medical Center San Pedro, medical records from the Lomita Post-Acute Care Center, emergency medical services records from the Los Angeles Fire Department, hospice records from the Providence Trinity Care Hospice, home health records from Legend Home Health, Inc., Eligibility check report from Efficient Home Health Services, Call recording from the Los Angeles Fire Department. IB interviewed three Facility Staff (S1-S3), two Residents (R2-R3), and six Witnesses (W1-W6).

INVESTIGATIONS REVEALED:

Allegation: Resident developed multiple pressure injuries while in care.

It is alleged resident developed multiple pressure injuries while in care. Reporting Party reported that R1 was admitted to Little Company of Mary San Pedro Hospital with at least 10 pressure injuries on 11/10/2019.

Based on IB’s records review, on 10/15/2019, R1 was admitted to the facility from Lomita Acute Center (LAC) with a healing stage 2 pressure injury on the left buttock and a deep tissue pressure injury (DTPI) on the right buttock. Physician’s Report (PR) and IB’s interview with Staff #1 confirmed R1 had pressure injuries on admission to the facility. PR indicates R1 had a nephrostomy. Upon discharge from Lomita Acute Center, R1’s attending physician ordered home health services with Efficient Home Health Services for R1’s physical, occupational, and speech therapies, along with skilled nursing. However, there was no record that R1 received home health services from this agency per the physician’s order. There was no record that R1 received home health services from 10/15/19 – 10/30/19. The Administrator, Angelique Gradney (S1), admitted during IB’s interview that she was unaware of the lapse of home health care for R1.

Medical records indicate R1’s Primary Care Physician signed a plan of care for home safety evaluation, disease process teachings, medication compliance, and skilled nursing services for a nephrostomy and catheter with a different agency (Legend Home Health) which commenced on 10/31/2019. The plan of care did not include wound care. There was no record that R1 received wound care from 10/15/2019 through 11/10/2019. IB conducted interview with Facility Caregiver and House Manager (S2) who stated, the administrator (S1) visits the facility once a month, while S2’s supervisor (S3), visits the facility weekly. S2 stated he was not sure who the home health provider was because he had zero documentation, but he

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20191119134759
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
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING II
FACILITY NUMBER: 198601924
VISIT DATE: 07/07/2022
NARRATIVE
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assumed it was Legend Home Health because this is the provider the facility typically uses. S2 stated, he denied having seen various pressure injuries when working with R1, with the exception of the coccyx pressure injury and one on R1’s leg which was observed when removing R1’s sock. S2 maintained he gave Brandelli daily bed baths and would have noticed the other pressure injuries had they been present. S2 stated, he checked on R1 every two hours but admitted sometimes allowing R1 to sleep without repositioning him, in order to avoid agitating him. During the course of IB’s investigation, the facility was not able to produce any home health records for R1.

On 11/10/2019, R1 was transported by paramedics to Providence Little Company of Mary Medical Center San Pedro for severe sepsis with septic shock in conjunction with acute renal failure and severe protein-calorie malnutrition. On admission to the hospital, R1 had multiple pressure injuries: right back (Stage 2), left back (DTPI), right heel (Unstageable), right lower lateral leg (DTPI), left lateral malleolus (DTPI), left lateral foot (DTPI), left media malleolus (DTPI), left medial foot (DTPI), bilateral buttock (Stage 2), left lateral elbow blisters (DTPI), right medial great toe (Stage 2) and right medial heel (Stage 2).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, Resident #1 developed deep tissue pressure injuries (DTPI) on left back, right lower lateral leg, left lateral malleolus, left lateral foot, and left media malleolus, left medial foot, unstageable pressure injury on the right heel along with stage 2 pressure injuries on right media great toe, right media heel, right back and bilateral buttock. Facility failed to observe R1 for changes in physical health condition and retained R1 with prohibited health conditions from admission (10/15/19) until resident’s discharge (11/10/19), therefore the above allegation “Resident developed multiple pressure injuries while in care” is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citations issued (ref. LIC 9099D) and civil penalty assessed.

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 copy of the Complaint Report and Appeal Rights were provided to ______.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20191119134759
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
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING II
FACILITY NUMBER: 198601924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2022
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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Staff Espino agreed to have the Administrator review and adhere to the section cited herein and shall submit a self-certification. Administrator shall conduct an in-service training on this section to all staff. POC shall be submitted to Lourdes.montoya@dss.ca.gov by the POC due date.
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Based on the department’s interviews and records review, Resident #1 developed deep tissue pressure injuries (DTPI) on left back, right lower lateral leg, left lateral malleolus, left lateral foot, and left media malleolus, left medial foot and Unstageable pressure injury on the right heel. The facility retained R1 with prohibited health conditions from admission (10/15/19) until discharged on 11/10/19. This poses an immediate risk to health, safety and/or personal rights to resident in care.
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CIVIL PENALTY ASSESSED

Type A
07/18/2022
Section Cited
CCR
87612(a)(10)
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87612 Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services:
(10) Stage 1 and 2 pressure injuries as specified in Section 87631(a)(3). This requirement was not met as evidenced by:
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Based on the investigations, R1 was admitted to the facility from Lomita Acute Center (LAC) on 10/15/2019 with a Stage 2 pressure injury and the licensee failed to ensure Resident #1 was provided with health services from 10/15/2019 until 10/30/2019. This poses an immediate risk to health, safety and/or personal rights to resident in care.
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Staff Espino agreed to have the Administrator review and adhere to the section cited herein and shall submit a self-certification. Administrator shall conduct an in-service training on this section to all staff. POC shall be submitted to Lourdes.montoya@dss.ca.gov by the POC due date.
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: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20191119134759
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
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING II
FACILITY NUMBER: 198601924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2022
Section Cited
CCR
87405(d)(1)(2)
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87405 Administrator - Qualifications and Duties –
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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Staff Espino agreed to have the Administrator review and adhere to the section cited herein and shall submit a self-certification.

POC shall be submitted to Lourdes.montoya@dss.ca.gov by the POC due date.
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The administrator failed to display knowledge of the requirements for providing care and supervision appropriate to the residents and knowledge of and ability to conform to the applicable laws, rules and regulations by failing to ensure R1 was provided with home health services by skilled medical professionals from 10/15/2019-10/30/2019 for stage 1 and stage 2 pressure injuries. The administrator also retained R1 who had prohibited health conditions from 10/15/2019 through 11/10/2019. This poses an immediate risk to health, safety and/or personal rights to resident in care.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5