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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701152
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:25:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
09/12/2024 and conducted by Evaluator Holly Williams
COMPLAINT CONTROL NUMBER: 27-AS-20240912224643
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 4DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Josevata TuragaTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff does not ensure resident is engaging in physical activities.
Staff did not ensure resident was transported to medical appointments.
Staff did not provide a comfortable environment for a resident in care.
Staff are not monitoring resident's health condition
Staff are not administering medication as prescribed
Facility did not ensure that staff are trained.
Staff did not ensure resident is provided with appropriate food and beverages.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Holly Williams and Vincent Moleski met with Josevata Turaga and together discussed the investigation details. Diane Garcia the administrator through text gave permission for Turaga to sign the report.
This investigation consisted of interviews, observations, and record review. LPA Williams interviewed administrator Diane Garcia. LPA Williams interviewed staff (S1-S2), 5 residents (R1-R5), case manager (CM), responsible party for R5 (RP) and home health nurses (HHN1-HHN2).
When LPA Williams visited the facility on 9/19/24 LPA Williams heard very loud music coming from R4’s room. LPA Williams asked S1 if he could ask R4 could turn the music down and S1 did. In an interview, R5’s RP when helping R5 move out there was loud music playing and 5 minutes after they arrived S1 turned it down. In an interview with R5 they stated that the loud music was distressing to R5. In an interview, CM said that they had heard the loud music, and it was distressing to R5.
[Continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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 7
Control Number 27-AS-20240912224643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
VISIT DATE: 12/23/2024
NARRATIVE
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In an interview, on 10/01/24, CM and HHN1 said they arrived at the facility on 9/6/24 to see R5 decompensating. In an interview, HHN1 said R5 was wheezing but R5’s lungs were clear. In an interview, HHN1 said it was anxiety. In an interview, HHN1 and CM said they asked S1 if S1 was administering R5’s inhaler and S1 said it was on the bed. In an interview, CM said they did not find an inhaler on the bed. In an interview CM and HHN1 said they looked for R5’s sensor on R5’s arm and it wasn’t there. In an interview, CM said S1 pulled out 2 bins with medication for R5 and HHN1 pulled out the inhaler and S1 said they had not seen that inhaler before. In an interview, both HHN1 and CM said that S1 had the Medication Administration Record (MAR) filled out to date but did not know what the medication looked like. In an interview, HHN1 said they asked if S1 is the one who gives all the medications to R5 and S1 said yes. In an interview, HHN1 said they asked where R5's diabetic monitor is and S1 said they did not know. In an interview, CM said on 9/25/24, S1 pulled out 2 bins with medication for R5 and the HHN1 pulled out the inhaler and S1 said S1 had not seen that inhaler before. In an interview, CM said that not all required medications were in the bin.
LPA Williams asked who gives the injections of insulin and HHN2 said the staff members do. In an interview, HHN2 said that HHN2 educated S1 on how to give the injection and to apply the diabetic monitors. In an interview, HHN1 said that nursing only goes there once a week. In an interview, HHN2 said that R5 could inject themselves when R5 is feeling good but there are times when R5 cannot inject themselves.

In an interview, on 9/6/24 CM said they took a picture of the food served to R5 and it was fried potatoes, hot-dogs with barbecue sauce and sent it to LPA Williams. In an interview with the administrator Garcia, Garcia told LPA Williams that Garcia has pictures of the meals that S1 is feeding to R5, When LPA Williams received pictures from Garcia, they were pictures of the diabetic meals that were sent to R5 by CM after they saw what R5 was eating. LPA Williams and Licensing Program Manager (LPM) Czarrina Camilon-Lee visited Golden Legacy II on 11/06/24 and went into R3’s room LPA Williams and LPM Camilon-Lee observed candy in a bag on the night stand and a bucket halfway filled with candy on the floor. When LPA Williams questioned S1 about the candy S1 said,” oh yeah R3’s family brought that.” LPA Williams reviewed R3’’s medical assessment (LIC602) that states R3 is pre diabetic and tests his blood sugar. LPA Williams reviewed the pre appraisal for R3 states that R3 should be on a diabetic diet and that R3 is taking Metformin which is a diabetic medication. In an interview, R5’s RP said that R5 would tell them that the food is not healthy, and the food was cold. In an interview, R5’s RP said R5 was served dinner while they were there, and RP had a chance to see the food the facility was serving. In an interview, R5’s RP said the food R5 was being served
[Continued on 9099-C]
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20240912224643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
VISIT DATE: 12/23/2024
NARRATIVE
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was all starch and they would call it, “Junk Food.” According to the medical assessment (LIC602) R2 is supposed to have a soft diet and while LPA Williams and LPM Czarrina Camilon Lee were there R2 was served a sandwich with chips and grapes.

In an interview, R5 stated that there was not planned activities. In an interview, R2, R5, and the CM all stated there are no planned activities. S4 said that there are not planned activities.

Through record review, LPA Williams found that S1 only had 36.5 hours of training done when starting work at the facility when 40 is required.

As a result of this investigation, LPA Williams finds the allegation(s) to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. The following deficiencies were cited per CCR Title section 87465(a)(4), 87628(b)(4), 87219(a)(4), 87468.1(a)(2), 87465(a)(2), 87411(c), and 87628(a).
An exit interview was conducted with Josevata Turanga. A copy of this report was provided to Josevata Turanga.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20240912224643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2024
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility...
This requirement was not met as evidenced by:
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Licensee agree's to write a statement of stating that the licensee will take the residents to and from their doctors appointments by the POC due date. Holly Williams@dss.ca.gov
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Based on observation, record review, and interview the facility did not take R5 to R5's doctor appointments which poses an immediate health, safety and/or personnel rights risk.
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Type B
12/31/2024
Section Cited
CCR
87411(c)
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 87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health...
This requirement was not met as evidenced by:
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Licensee agrees to write a statement committing to having all initial training which is 40 hours completed before an employee starts working at the facility by POC due date.
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Based on observation, record review, and interview S1 did not have 40 hours total of training before starting employment with the facility which poses an potential health, safety and/or personnel rights risk.
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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: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20240912224643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed...
This requirement was not met as evidenced by:
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Licensee agrees to retrain all staff members on how to store medication and how to administer medication.
Licensee agrees to provide a written plan on when training will be and will send to LPA Williams by POC due date. When training is finished licensee agrees to send the sign in sheet and training materials to LPA Williams on date of statement of training.
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Based on observation, record review, and interview S1 did not administer R5's inhaler which poses an immediate health, safety and/or personnel rights risk.
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Type A
12/24/2024
Section Cited
CCR
87628(b)(4)
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87628 Diabetes
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7).
This requirement was not met as evidenced by:
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Licensee agrees to retrain all staff members on specialized diets. Licensee agrees to provide a written plan on when training will be by POC due date and will send LPA Williams the sign in sheet and training material by date on statement of training. date.Holly.williams@dss.ca.gov
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Based on observation, record review, and interview S1 did not prepare meals for residents that according to the Physicians report need a diabetic diet and allowed R3 who is on a diabetic diet to have candy in their room which poses an immediate health, safety and/or personnel rights risk.
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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: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20240912224643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2024
Section Cited
CCR
87219(a)(4)
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87219 Planned Activities
a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (4) Physical activities such as games, sports and exercise which develop and maintain strength, coordination and range of motion.
This requirement was not met as evidenced by:
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Licensee agrees to retrain all staff members on planned activities and send LPA Williams a calendar with scheduled planned physical activities by POC due date. Licensee agrees to provide a written plan on when training will be and will send LPA Williams the sign in sheet and training materials by statement of planned training due date. Holly.williams@dss.ca.gov
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Based on observation and interview Licensee does not provide planned activities or physical activities which poses an potential health, safety and/or personnel rights risk.
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Type B
12/30/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations...
This requirement was not met as evidenced by:
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Licensee agrees to write a statement of understanding that all residents have the right to live in a comfortable enviroment. and explaining what the licensee will do in the future to meet that requirement by POC due date. Holly.williams@dss.ca.gov
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Based on observation, record review, and interviews S1 and licensee did provide a comfortable living enviroment which poses an potential health, safety and/or personnel rights risk.
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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: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20240912224643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
87628(a)
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"(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional." This requirement was not met as evidenced by:
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Licensee agrees to send a plan for training of all staff on change of conditions and reporting to administrator of change of conditions.Send this plan to LPA Williams by POC due date. Holly.williams@dss.ca.gov
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Based on observation and interviews, a resident was not able to perform their own blood glucose testing or injections, and staff were not monitoring their ability to do so, which poses an immediate health, safety and/or personnel rights risk.
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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: Holly Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
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