198601924-3-6-2022-11-AS-EMAZ-CCRVJV-20220322162922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601924
Report Date: 02/24/2022
Date Signed: 03/06/2022 07:40:04 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
01/13/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220113160924

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:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Catherine Espino		TIME COMPLETED:	03:31 PM

ALLEGATION(S):

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Staff is not observing changes in residents’ health.
Staff is not administering medication as prescribed by the physician.
Staff are not assisting resident with incontinence care.
Resident is not getting three meals a day.
Resident’s mattress is soiled with urine.
Staff did not ensure the resident had clean clothes.
Resident is not receiving assistance with hygiene and grooming.

INVESTIGATION FINDINGS:

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On 02/24/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. LPA met with caregiver Penny Tan and explained the purpose of today's visit is to gather information for the allegations mentioned above. Catherine Espino the administrator was notified by telephone and was present at the facility during the inspection.

The investigation consisted of the following: LPA inquired questions relevant to the nature of the complaint. A review of resident #1 (R1) service records and other pertinent documents in association with the allegations. An interview with residents, staff, and witnesses. A tour of the facility was conducted on 01/19/22, 02/10/22, and 02/22/22.

Evaluation Report continues on LIC 9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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-20220113160924

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: 02/24/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident is not getting three meals a day.
The details of the complaint state resident #1 (R1) is not given not meals. It is alleged that on 01/13/22, that (R1) was not provided breakfast that morning. An interview with (R1) refutes this allegation. (R1) states he receives all three meals that consist of breakfast, lunch, and dinner. (R1) has no recollection of claiming he was deprived of a meal. Interviews conducted with staff #1-#4 (S1-S4) all dispute this allegation. (S1-S4) reported (R1) receives all his meals daily along with snacks. Interviews conducted with family members witnesses #2-#3 (W2-W3) also deny this allegation. The Department observed a monthly menu was posted and visible to residents, staff and visitors. Based on the information gathered, there is no evidence to support this allegation mentioned above.

Allegation: Resident's mattress is soiled in urine.
Staff is not assisting the resident with incontinence care.
The complainant alleges resident #1 (R1's) mattress is soiled in urine and staff failed to assist with incontinence care. An interview with (R1) states the staff does help daily with his incontinence care. (R1) does not recall if ever he was left for an extended period within soiled diapers or soiled mattresses. Interviews with witnesses #2-#3 (W2-W3) along with resident #2 (R2) reported no resident has been left in soiled diapers or soiled mattresses for an extended period. Staff #1-#4 (S1-S4) claim these allegations are false and that (R1) is assisted daily with incontinence care. Furthermore, no residents have been left in soiled mattresses for an extended period as this is not allowed according to the administrator. Based on observation and information gathered, there is no evidence to corroborate the allegations mentioned above.

Allegation: Staff did not ensure residents had clean clothes.
Resident is not receiving assistance with hygiene and grooming.
The details of the complaint state resident #1 (R1) did not have clean clothes or was assisted with his personal care. It is alleged (R1) appeared disheveled in an appearance on 01/13/22. An interview with (R1) states he is helped daily with his hygiene and grooming. (R1) claims that he spills stuff on his clothing all the time and that his clothing is changed daily or when required. Interviews with resident #2 (R2) and witnesses #2-#3 (W2-W3) report they have no issue with care and services provided and have not observed (R1) not being assisted with hygiene and grooming.
Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220113160924

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: 02/24/2022

NARRATIVE

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No one has witnessed (R1) in unclean clothing including staff #1-#4 (S1-S4) for an extended period. Based on observation and information gathered, there is no evidence to corroborate the allegations mentioned.

Allegation: Staff is not administering medication as prescribed by the physician.
Staff is not observing changes in residents' health.
The complainant alleges that the staff is not administering medications for resident #1 (R1) as prescribed by his physician on 01/13/22. The complainant also alleges the staff has failed to observe for changes in (R1s) health. The Department reviewed (R1's) service records indicate an assessment was health condition was performed on 10/14/21 and was evaluated by his primary physician on 10/11/21. An interview with (R1) claims that staff is responsive daily in observing for any changes in his health. (R1) claims there are two staff members in each shift at all times to assist with his care. (R1) claims that he can not recall ever a time he was denied with his medications and believes that staff administers his medications according to his doctor's orders. During interviews with staff #1-#4 all verified that (R1) receives his prescribed one (1) medication according to doctor's orders. Interviews with resident #2 (R2) and witnesses #2-#3 (W2-W3) claim they have not encountered issues with their prescribed medications and it is being administered according to doctor's orders. Moreover, (W2-W3) states the staff is attentive to residents' changed conditions. Interviews with staff #1-#4 (S1-S4) assert that these allegations are false. (S1) expresses the staff has the experience and training background to handle these concerns. Based on information gathered, there is no evidence to support these allegations mentioned above.

Based on information collected, an inspection of the facility, observation, analysis of (R-1)'s service records, and interviews conducted, the Department found no evidence in support to validate all allegations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Catherine Espino and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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