286804071-8-13-2024-21-AS-KMOA-D8AQ8K-20240819115652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804071
Report Date: 08/13/2024
Date Signed: 08/13/2024 09:53:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20240315155856

FACILITY NAME:	GOLDEN HEARTS SENIOR CARE, LLC		FACILITY NUMBER:	286804071
ADMINISTRATOR:	MANALO, EDWARDSON		FACILITY TYPE:	740
ADDRESS:	1630 ARCADIA COURT		TELEPHONE:	(415) 770-4285
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 5	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Edwardson Manalo		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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9

Staff do not allow residents to leave the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation site visits were made; staff, residents and witnesses were interviewed as well as documents obtained and reviewed. Based on the statements and reviewed documents, the following determinations are made: Residents have differing opinions as to whether or not there are sufficient opportunities to leave the facility for community outings and have made contradictory statements regarding desire to leave facility; Staff state that they are prepared to arrange for transportation to the community when requested by residents or family; Facility's arrangements with third party transportation entities is in compliance with approved Plan of Operation. Although the allegation may be true, or valid, based upon the statements made, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.

Report left.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20240315155856

FACILITY NAME:	GOLDEN HEARTS SENIOR CARE, LLC		FACILITY NUMBER:	286804071
ADMINISTRATOR:	MANALO, EDWARDSON		FACILITY TYPE:	740
ADDRESS:	1630 ARCADIA COURT		TELEPHONE:	(415) 770-4285
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 5	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Edwardson Manalo		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
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8
9

Staff do not have activities for residents in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
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9
10
11
12
13

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation site visits were made; staff, residents and witnesses were interviewed as well as documents obtained and reviewed. Based on the statements and reviewed documents, the following determinations are made: At two unannounced site visits only one activity (leg exercises) was identified as having occurred that day; The Month’s Activity Calendar lists in excess of 30 planned activities, only 3 of which had recently occurred( leg exercise, walking, coloring) according to staff; Daily Notes for July, 2024, do not indicate that the planned activities outlined on the calendar were offered or refused by residents and show only some computer activity, movies, and walks. Based upon the statements and documents, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
87219(

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20240315155856

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 286804071
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/13/2024 Section Cited CCR 87219(a)	1 2 3 4 5 6 7	87219(a) Planned Activites. Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities… Based on statements and documents, this requirement has not been met as evidenced by: During the	1 2 3 4 5 6 7	Administration to submit documentation of activities planned for residents over a 30 day period with notations indicating the activity, who participated or refused. Activities to be selected from approved sample activities calendar. Due by POC date in order to clear the deficiency
	8 9 10 11 12 13 14	month of July, 2024, none of the posted activities were offered or refused except for computer activity, walks, movies. Unannounced site visits indicate staff were not providing posted activities. This poses a potential denial of residents’ right to services.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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