336402995-11-18-2022-18-AS-NBRN-CLLVQZ-20221128153910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336402995
Report Date: 11/18/2022
Date Signed: 11/18/2022 01:31:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2020 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201204140456

FACILITY NAME:	GOLDEN CARE SENIOR LIVING ON WILSON		FACILITY NUMBER:	336402995
ADMINISTRATOR:	VELOSO, JUANITA		FACILITY TYPE:	740
ADDRESS:	5466 W. WILSON		TELEPHONE:	(951) 845-7734
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	0	CENSUS: 21	DATE:	11/18/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Nymia Pontillas, care provider		TIME COMPLETED:	01:33 PM

ALLEGATION(S):

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Resident's hygiene needs have not been addressed while in care.
Facility has inadequate record keeping.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Anna Bueno and Amber Coleman conducted an unannounced visit to the facility to investigate the above mentioned complaint allegation and deliver findings. LPAs identified themselves to care provider Nymia Pontillas who was notified of the reason for today’s visit. Administrator Jasmin Dolores was phoned by staff and informed of the elements of the allegation. The investigation included resident and staff interviews, facility observations, and records review.

Allegation 1: Resident's (R1) hygiene needs have not been addressed while in care. LPAs were unable to interview R1 as they no longer reside in the facility. Records reviewed and staff interviews revealed that R1 was able to complete activities of daily living (ADL) with prompting and staff assistance. LPAs observed residents who appear well-groomed and dressed appropriately. LPAs also observed the physical plant to be clean and orderly. Based on the information obtained, the allegation is unsubstantiated.

Allegation 2: Facility has inadequate record keeping. LPAs reviewed 5 records with admissions dates from or

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

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 18-AS-20201204140456

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN CARE SENIOR LIVING ON WILSON	FACILITY NUMBER: 336402995
	VISIT DATE: 11/18/2022

NARRATIVE

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before 2020 and did not find another resident record mixed in the file. LPAs reviewed R1's archived file and only found R1's records. This allegation is unsubstantiated.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Ms. Nymia Pontillas and a copy of this report was provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

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