312700634-3-2-2022-25-AS-LMUZ-CC6TSV-20220303135946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700634
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:57:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2022 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 25-AS-20220112143349

FACILITY NAME:	GOLDEN HILLS CARE HOME, INC.		FACILITY NUMBER:	312700634
ADMINISTRATOR:	DIZON, LISA		FACILITY TYPE:	740
ADDRESS:	1434 ELM ST		TELEPHONE:	(916) 474-4920
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS: 5	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Lisa Dizon		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents sustained unexplained bruising

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 03/02/22, Licensing Program Analysts (LPA) Kevin Mknelly and Talwinder Bains conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with staff. Prior to entering for the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPAs were screened for symptoms and temperature at the facility.

LPAs conducted records review and extensive interviews.
The department is unable to find and or meet the preponderance, per policy.

Records review and interviews conducted by the department between January 13, 2022 and February 17,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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 2

Control Number 25-AS-20220112143349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GOLDEN HILLS CARE HOME, INC.	FACILITY NUMBER: 312700634
	VISIT DATE: 03/02/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

2022 found that during a routine visit, a hospice nurse (HN) found that R1 and R2 had bruises. R2 had a bruise on their wrist and R1 had a large bruise on their shin. When HN asked the staff who were present about it, that staff stated that they did not know the time or cause of bruising. HN asked the Administrator about the bruising and the Administrator had not been informed of them either.

HN was then provided an explanation from facility staff that residents had developed reflexive movements while in bed or being assisted where they would stiffen or kick out. HN then observed that when R1 is moved, they stiffen and reflexively kick their feet out, especially at the dining table. When the side rail is up on her bed, R1 will stiffen and kicks the side rail. This was a new thing R1 started doing, but staff did not communicate the change to hospice before bruises were observed. After spending time working with the staff and looking into it, HN was confident that staff were not mistreating residents.

Facility staff initiated padding residents’ bed rails and hospice provided additional changes. Resident conditions resolved.

Licensee was advised by LPAs that all changes in condition or needs for services be communicated timely to Hospice. It was additionally advised that all bruises or wounds to residents be reported to Community Care Licensing.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Report reviewed with staff and copy provided.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2