315002894-6-1-2023-25-AS-KHOS-CSJP5E-20230606110037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002894
Report Date: 06/01/2023
Date Signed: 06/01/2023 11:10:37 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20230221102112

FACILITY NAME:	GOLDEN HILLS CARE HOME		FACILITY NUMBER:	315002894
ADMINISTRATOR:	MAHAJAN, VIVEK		FACILITY TYPE:	740
ADDRESS:	1434 ELM STREET		TELEPHONE:	(916) 474-4920
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS: 4	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Vivek Mahajan, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility staff did not report injury to resident's responsible person.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings for allegation listed above. LPA met with Administrator Vivek Mahajan during today's inspection.
LPA investigated allegation, "Facility staff did not report injury to resident's responsible person". LPA interviewed administrator in which he stated R1 moved into the facility on 12/09/22. Resident was dropped off at the facility by a medical transport vehicle and the driver, not an employee, was pushing R1 in a wheelchair toward the facility. During transport by the driver R1's leg was bumped and R1 was in pain but no injury was noted. Administrator stated he does not remember if he reported that incident to responsible party and no documentation was available.
Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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 25-AS-20230221102112

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN HILLS CARE HOME	FACILITY NUMBER: 315002894
	VISIT DATE: 06/01/2023

NARRATIVE

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Administrator stated there were no other incidents or injuries that occurred during R1's stay at the facility. LPA interviewed home health agency in which they stated in January 2023 they observed a pressure injury to R1's shin. R1 was seen by a wound specialist in which they stated the injury came from a incident that caused the injury. Home health spoke to R1 at the time and learned that during a transfer from bed to wheelchair the caregivers hit her shins on medical equipment. Responsible party stated this incident was not reported to her. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D.

Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20230221102112

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN HILLS CARE HOME	FACILITY NUMBER: 315002894
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.	1 2 3 4 5 6 7	Administrator agrees to review 87211 reporting requirements and send into LPA a statement of understanding. Statement to be sent into CCL by 6/09/23.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews the licensee did not report incident which lead to R1's pressure injury which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Since incident occurred facility has begun to complete thorough documentation for each resident.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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