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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002876
Report Date: 11/06/2023
Date Signed: 11/06/2023 02:01:07 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
11/03/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20231103161851
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: 2DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stephanie Harmon-Christensen, CaregiverTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility staff are not receiving required training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Caregiver, Stephanie Harmon-Christensen, to conduct a complaint investigation into the allegation listed above. During visit owner, Mark Graham, gave permission for caregiver to sign report.

During today's visit, LPA reviewed documentation pertinent to the investigation. During visit, LPA reviewed five caregiver files for staff members S1, S2, S3, S4, and S5. LPA observed that no staff files reviewed had any trainings documented, including CPR, first aid, and any annual or initial training.

Based on 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, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
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 4
Control Number 59-AS-20231103161851
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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2023
Section Cited
CCR
87411(c)(1)
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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 and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
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Facility will ensure that all caregivers receive first aid training and ensure that first aid certificates are updated regularly as required. Facility will submit proof of training to LPA by POC due date of 11/14/2023.
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Based on records reviewed, facility did not ensure that caregivers received first aid training by an agency such as American Red Cross, which poses a potential health, safety, and personal rights risk to the residents in care.
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Type B
11/14/2023
Section Cited
HSC
1569.618(c)(3)
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§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
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Facility will obtain CPR training for caregivers and ensure that there is at least one (1) caregiver who is CPR trained at the facility at all times. Facility will submit proof of training to LPA by POC due date of 11/14/2023.
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Based on records reviewed, facility did not ensure that there was at least one (1) staff member with CPR training on the premises at all times, which poses a potential health, safety, and personal rights risk to the 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: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20231103161851
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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2023
Section Cited
HSC
1569.625(b)(1&2)
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§1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
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Facility will ensure that caregivers receive required initial and annual training and maintain documentation of training at the facility. Facility will submit proof of training for caregiver to LPA by POC due date of 12/05/2023.
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Based on records reviewed, facility did not ensure that staff were acquiring all required trainings per Health and Safety Code, which poses a potential 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
11/03/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20231103161851

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: 2DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stephanie Harmon-Christensen, CaregiverTIME COMPLETED:
02:05 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility staff do not have criminal background clearance
INVESTIGATION FINDINGS:
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5
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7
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13
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Caregiver, Stephanie Harmon-Christensen, to conduct a complaint investigation into the allegation listed above. During visit owner, Mark Graham, gave permission for caregiver to sign report.

During today's visit, LPA reviewed documentation pertinent to the investigation. During visit, LPA reviewed criminal background clearance for staff members S1, S2, S3, S4, and S5. LPA observed that all staff reviewed obtained criminal background clearances.

Based on records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is 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. A copy of this report and appeal rights were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4