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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002876
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:09:28 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
12/27/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241227081444
FACILITY NAME:GOLDEN MOMENTS CARE HOME WINDING WAYFACILITY NUMBER:
345002876
ADMINISTRATOR:DAHLEY, DALEEFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 474-4678
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 3DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Mark Graham, LicenseeTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff are mismanaging residents' medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Mark Graham, to deliver findings regarding the complaint allegation listed above.

During the course of the investigation, LPA conducted interviews, conducted a medication count, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Staff are mismanaging residents' medication

** Report continued on 9099-C **

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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 5
Control Number 59-AS-20241227081444
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 MOMENTS CARE HOME WINDING WAY
FACILITY NUMBER: 345002876
VISIT DATE: 01/16/2025
NARRATIVE
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During a visit conducted on 1/16/2025, LPA conducted a medication count for residents R2 and R4, comparing the residents' Centrally Stored Medication Form (CSM) with medications centrally stored for the residents. LPA observed one (1) medication for R2 that was off count in relation to what was documented. Medication that was off count was under the amount documented. There were no documentation to account for medication that was under the amount documented. LPA observed two (2) medications for R4 that were off count in relation to what was documented. One (1) medication that was off count was over the amount documented and one (1) medication that was off count was under the amount documented, There were no documentation to account for medications that were off count.

Based on medication count, LPA's observation, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20241227081444
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 MOMENTS CARE HOME WINDING WAY
FACILITY NUMBER: 345002876
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2025
Section Cited
CCR
87465(a)(4)
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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 (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility will ensure that medications are being administered as prescribed. Facility will complete a statement of understanding regarding regulation 87465 and submit statement to LPA by POC due date.
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Based on medication count and records reviewed, the facility did not ensure that residents R2 and R4 were receiving medications as prescribed, which poses an immediate health, safety, and personal rights 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/27/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241227081444

FACILITY NAME:GOLDEN MOMENTS CARE HOME WINDING WAYFACILITY NUMBER:
345002876
ADMINISTRATOR:DAHLEY, DALEEFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 474-4678
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 3DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Mark Graham, LicenseeTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Unqualified staff were administering injections to resident

Staff are not meeting residents' hygiene needs

Staff are not ensuring resident was seen by a doctor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Mark Graham, to deliver findings regarding the complaint allegations listed above.

During the course of the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Unqualified staff were administering injections to resident

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20241227081444
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 MOMENTS CARE HOME WINDING WAY
FACILITY NUMBER: 345002876
VISIT DATE: 01/16/2025
NARRATIVE
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Interview with Administrator, Mark Graham, indicated that resident (R1) was able to administer their own injectable medications. Interview with staff member (S2) indicated that they were responsible for making sure R1 received the right amount of their injectable medication, but R1 self administered their own injectable medication. LPA observed a Physician's Report LIC 602A for R1 dated 10/01/2024, which indicated that R1 was able to administered their own injectable medication. Interviews with resident R2, R3, and R4 indicated that they had no concerns regarding medication administration at the facility.

Allegation: Staff are not meeting residents' hygiene needs

Interviews with staff members S1, S2, and Administrator indicated that the residents receive sufficient care with bathing, grooming, and hygiene. Interviews with R2, R3, and R4 indicated that they had no concerns regarding facility staff assisting with bathing, grooming, and hygiene. LPA observed records documented by S2 showing multiple dates in which R1 refused showers.

Allegation: Staff are not ensuring resident was seen by a doctor

Interview with Administrator indicated that R1 had a doctor assigned to them outside of the area and was working on finding a local doctor. Administrator stated that R1 was resistant when facility attempted to assist R1 with locating medical assistance in the area. LPA observed After Visit Summaries dated 11/16/2024 and 12/06/2024 indicating that R1 was seen by a medical professional for different conditions. Interviews with R2, R3 and R4 indicated that they had no concerns regarding being seen by a doctor.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Licensee. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5