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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002894
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:10:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230613163958
FACILITY NAME:GOLDEN HILLS CARE HOMEFACILITY NUMBER:
315002894
ADMINISTRATOR:MAHAJAN, VIVEKFACILITY TYPE:
740
ADDRESS:1434 ELM STREETTELEPHONE:
(916) 474-4920
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 4DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Staff: Louie DizonTIME COMPLETED:
08:48 AM
ALLEGATION(S):
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- Staff did not provide adequate supervision resulting in a resident wandering away from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 08/31/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 06/13/2023. LPA met with staff, Louie Dixon, and explained the purpose of the visit.Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s physician’s report and appraisal/needs and services plan.

According to complainant, complainant observed R1 wandering the road on 06/13/2023. Shortly after observing R1 wandering, the facility staff were seen searching in the neighborhood and running down the street.

Continue on page LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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
Control Number 59-AS-20230613163958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 315002894
VISIT DATE: 08/31/2023
NARRATIVE
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The Department requested for R1’s physician’s report. According to R1’s physician’s report, R1 has dementia and is not able to leave the facility unassisted. The Department received interview statements from a total of three (3) facility staff and R1's responsible party. Interview statement received from administrator indicated, administrator was not working when R1 eloped on 6/11/2023. R1 eloped and was found at an elementary school located about six (6) minutes away from the facility due to staff’s lack of supervision. R1 was located by a mail lady. It took staff approximately 22-30 minutes to locate R1. R1's RP indicated there is sufficient staffing to meet R1's needs and that staff are attentive to R1. This incident was a one time occurrence.

Based on evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D.

Exit interview conducted and report provided. Appeal rights were provided.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20230613163958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 315002894
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: It was determined that staff did not provide adequate care and
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The administrator agrees to provide a detailed plan explaining how they will ensure facility staff are competent and aware of how to properly provide care and supervision to residents. Proof of completion shall be sent to the licensing agency by 9/1/2023.
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supervision to R1 which resulted in R1 eloping to an elementary school six minutes away from the facility. It took staff approxmiately 22-30 minutes to locate R1 which poses an immediate 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3