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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701152
Report Date: 10/31/2022
Date Signed: 10/31/2022 04:15:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/27/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221027090944
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 6DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Diana Garcia TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident leaving the facility.
Resident sustained a fall due to lack of care and supervision.
staff did not provide medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/31/2022 at 1:47 PM to open a complaint and deliver findings, LPA Martinez met with Diana Garcia, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and obtained facility records. On October 22, 2022, staff 1 (S1) left the residents unsupervised at 10:30 PM, and resident 1 (R1) eloped from the facility during this time. Law enforcement was called on October 22, 2022, and R1 was returned to the facility and later sent to the hospital on this day. R1 also, eloped from the facility on October 24, 2022 at 3 AM. R1 was returned to the facility by Law Enforcement on October 24, 2022. Moreover, on October 24, 2022, Law enforcement found resident 2 (R2) on the floor next to their bed. It is unknown how long R2 was on the floor, and R2 was not provided medical attention until Law Enforcement found R2.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
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 4
Control Number 27-AS-20221027090944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
VISIT DATE: 10/31/2022
NARRATIVE
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During the October 24, 2022 incidents, it was learned S1 locked their bedroom door and went to sleep. On this day, Law Enforcement knocked on S1 bedroom door for a long period of time due to S1 being asleep and unresponsive. Per interviews it was learned S1 went to sleep at 12 AM, and left the residents unsupervised and without care.

As a result of today's case management, on October 31, 2022 an immediate civil penalty in the amount of $500 has been issued for the violation of Section 87464 (f)(1). This immediate civil penalty was issued to the Licensee due to absence of care and supervision on October 22, 2022 and October 24, 2022 for R1's elopements.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of this report was provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20221027090944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by:
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Licensee agrees to conduct Basic Services training to all staff by 11/01/2022 by close of business 5 PM. Licensee will email training document and work schedule to LPA Martinez by 11/01/2022 by close of business 5 PM. Work on hiring an awake NOC shift staff.
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Based on interviews and file reviews, the Licensee did not ensure resident 1 was supervised and provided care at all times on 10/22 and 10/24. which led to R1 eloping from facility. This posed an immediate health and safety risk to residents in care.
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Email LPA Martinez hiring plans by 11/01/2022 by close of business 5 PM.
Type A
11/14/2022
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(4). To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by
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Licensee agrees to conduct Personal rights training to all staff by 11/01/2022 by close of business 5 PM. Licensee will email training document and work schedule to LPA Martinez by 11/01/2022 by close of business 5 PM
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evidence by: Based on file reviews and interviews, the Licensee did not ensure R2 was provided care and supervision which resulted in a fall.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20221027090944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2022
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care:The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This requirement was not met as evidence by: Based on interviews and record reviews
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Licensee agrees to conduct Incidental Medical and Dental training to all staff by 11/01/2022 by close of business 5 PM. Licensee will email training document and work schedule to LPA Martinez by 11/01/2022 by close of business 5 PM.
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The Licensee did not ensure R2 received timely medical attention after their fall. This posed an immediate health and safety risk to R2.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4