347002359-10-30-2023-27-AS-KHOS-CXBLQK-20231106075740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347002359
Report Date: 10/30/2023
Date Signed: 10/30/2023 11:44:27 AM

Unsubstantiated

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
09/08/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20230908160341

FACILITY NAME:	GOLD CARE INC		FACILITY NUMBER:	347002359
ADMINISTRATOR:	GOLD, NORMA		FACILITY TYPE:	735
ADDRESS:	7158 CLEARBROOK WAY		TELEPHONE:	(916) 689-2045
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	4	CENSUS: 1	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Norma Gold		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)s Jamie Ivey Canady at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Norma Gold.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with residents, interviews with staff, and review of resident files.

The Department has determined the following as it relates to the allegations: Staff hit resident

Continued on LIC 9099 - C...
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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 27-AS-20230908160341

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: GOLD CARE INC	FACILITY NUMBER: 347002359
	VISIT DATE: 10/30/2023

NARRATIVE

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On 9/14/2023 Licensing Program Analyst (LPA) Ivey Canady interviewed facility staff regarding current facility allegations. LPA requested and received facility resident files to include resident transaction receipts, resident files, resident medical records and Sacramento County Police Record Number. According to resident medical files, R1 is diagnosed with Mild Intellectual Disability and Infantile Epilepsy. According to staff interviews, R1 speaks of situations that have not occurred and frequently changes information regarding similar stories. Based on interviews with facility licensee, R1 has a history of creating stories that are not true. During review of R1's Individual Program Plan (IPP), it was learned R1 stated there had been a hit upon the head months ago during a planning meeting with R1's Alta Regional Center Service Coordinator and R1's conservator. When asked about the incident again during the planning meeting R1 stated the hit had happened 5 days prior. On 10/30/2023 LPA requested and received R1's complete file. According to document review, there has been other circumstances similar to current facility allegations and the police have been unable to take further action due to inconsistencies in R1's statements. R1's history of creating stories is documented and the facility institutes actions based on R1 behaviors based on the data collection plan devised by R1's behaviorist. On 10/30/2023 during LPA's continued document review it was learned, R1's program advisor at the R1's day program stated R1 has issues with memory. On 10/24/2023 LPA conducted an interview with R1. According to interview with R1, R1 stated confusion as to whether there was a hit on the head or if there was a memory related to having had surgery on the head. R1 did not remember having telling anyone there had been a hit on the back of the head. Based on LPA observation, R1 is not clear of any incident regarding being hit on the back of the head. During review of facility resident medical files, there was no incident or medical reports regarding R1 having had a medical assessment for a possible head injury. Based on staff and witness interviews, review of facility and medical files and interview with R1, the allegation, Staff hit resident is unsubstantiated.
An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Norma Gold

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

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