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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601924
Report Date: 02/10/2022
Date Signed: 02/11/2022 10:32:25 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 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:
02/10/2022
UNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:IRISH BURL BALDEVIA TIME COMPLETED:
03:51 PM
ALLEGATION(S):
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Staff did not have documentation of the resident’s medical history.
Staff did not have documentation of the resident’s medications.
Staff did not provide residents with clean linens.
The facility smells like urine.
INVESTIGATION FINDINGS:
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On 02/11/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. LPA met with caregiver Irish burl Baldvia and explained the purpose of today's visit is to deliver findings for the allegations mentioned above. Catherine Espino the administrator was notified by telephone and was not able to make it to the facility.

The findings were read to the administrator by telephoneThe investigation consisted of the following: LPA observation, photographs, service record reviews and interviews with staff #1-#3 (S1-S3), and a tour of the facility.

Evaluation Report continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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 6
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: 02/10/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not have documentation of the resident’s medical history.
Staff did not have documentation of the resident’s medications.
The complainant alleges that the facility did not have documentation of the resident’s #1 (R1) medical history and medications available. On 01/19/22 at 2:40 pm, the Department reviewed (R1's) service records and found a missing Admission Agreement, Physicians Report LIC 602A, and Preplacement Appraisal LIC 603. The facility also had incomplete Medication Administration Records (MARs) of (R1’s) medications. (R1) was admitted on 10/14/21 and did not have a record of medications being administered from 12/01/21 through 01/12/22. The Department observed one prescribed medication was refilled on 01/13/22. During an interview with staff #1-#3 all verified that (R1) received his prescribed medications daily but was unable to account for missing information on (MARs). (S1) reports service records were available for (R1) off-site. (S1) submitted missing service records on 01/21/22 to the Department.

Allegation: Staff did not provide residents with clean linens.
The details of the complaint state resident #1 (R1) was not provided with clean linens. On 01/19/22 at 3:32 pm, the Department inspected (R1’s) bed linens and observed dirty sheets with stains that appeared to be excreta and food particles. An interview with staff #2 (S2) reported that (R1) had just completed eating his meal and that it was food droppings. (S2) claims that (R1’s) bed linens are changed regularly. However, he was unable to specify a schedule if bed linens are changed as required. According to (S2) lunch meals were provided at 12:00 pm, which indicates (R1) remained with unchanged bed linens for more than several hours.
Allegation: The facility smells like urine.
The details of the complaint state the facility appeared to be unclean with a stench of urine permeating through the house. On 01/19/22 at 3:33 pm, the Department conducted a plant inspection of the entire facility and found dirty bathrooms and kitchen. (R1's) bathroom was unhealthy with speckles of feces on the floor. The kitchen stove and refrigerator were unclean and unsanitary. The facility had an unpleasant scent as soon as the front door is opened it reeked a fetid odor of urine.

Evaluation Report continues on LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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: 02/10/2022
NARRATIVE
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Based on the Department’s observations, photographs, records that were reviewed (physician’s report, appraisal/needs and services plan, medications), and the interviews that were conducted with staff #1-3, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview conducted, and a copy of this report was provided to Catherine Espino.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2022
Section Cited
CCR
87506(a)
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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This citation poses a potential health and safety risk to residents in care.
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The licensee will ensure that all residents have complete resident's service records which includes a physician's reports. The licensee will submit complete files for R3 and R5 by POC due date 02/21/22
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee failed to adhere to Title 22. Licensee did not have physician's report for R3 and R5. This citation poses a potential health and safety risk to residents in care.
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Type B
02/21/2022
Section Cited
CCR
87303(a)(1)
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87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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The licensee will ensure adhere to Title 22 regulaitons and to maintain the facilty in clean, safe and sanitary at all times. The licensee will have to perform deep cleaning for all bathroom and kitchen surfaces by POC due date 02/21/22.
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This requirement was not met as evidenced by:
Based on observations and photographs the Licensee failed to adhere to Title 22 regulations. Licensee failed to maintain the facility in a sanitary and odorless condition. This citation poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2022
Section Cited
CCR
87307(3)(c)
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87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident… (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, ...The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair…
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The licensee will adhere to Title 22 regulations and ensure that all resident’s personal accommodations and services adequate and in good practice that clean sheets are used by residents are all times. The licensee will submit complete files for R3 and R5 by POC due date 02/21/22
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This requirement was not met as evidenced by:
Based on observation and photographs, the Licensee failed to adhere to Title 22 regulations. Licensee did not clean unstained bed linens for (R1).
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Type B
02/21/2022
Section Cited
CCR
87465(e)(1-4)
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87465(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.The specific symptoms which indicate the need for the use of the medication. (2) The exact dosage. (3)The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period.
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The licensee will ensure that all residents have complete complete documentation of medications (MARs). The licensee will submit proof of correction by 02/21/22.
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee failed to adhere to Title 22 . Licensee did not have prescribe medications documented on MARs. This citation poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6