347004362-2-9-2021-27-AS-KHOS-BY5QKP-20210211111439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004362
Report Date: 02/02/2021
Date Signed: 02/09/2021 01:55:14 PM

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
11/30/2020 and conducted by Evaluator Jasmine McCrory

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201130090407

FACILITY NAME:	GOLDEN MOMENTS CARE HOME, INC.		FACILITY NUMBER:	347004362
ADMINISTRATOR:	MAKAYLA WHITE		FACILITY TYPE:	740
ADDRESS:	2651 ARMSTRONG DR.		TELEPHONE:	(916) 979-9828
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	6	CENSUS: 5	DATE:	02/02/2021
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Makayla, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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** This document was created by Licensing Program Analyst (LPA) McCrory on 02/09/2021 to update findings that were delivered on 02/02/2021 from unsubstantiated to unfounded. Below is a copy of the report.**

On 02/02/2021 at 2:30 PM Licensing Program Analyst (LPA) McCrory conducted an unannounced visit to the facility to deliver findings for the above allegations. Prior to visit, LPA conducted self-assessment and had no COVID-19 related symptoms. During visit, LPA was in full Personal Protective Equipment (PPE) while at the facility.

(continued)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021

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-20201130090407

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 MOMENTS CARE HOME, INC.	FACILITY NUMBER: 347004362
	VISIT DATE: 02/02/2021

NARRATIVE

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** This document was created by Licensing Program Analyst (LPA) McCrory on 02/09/2021 to update findings that were delivered on 02/02/2021 from unsubstantiated to unfounded. Below is a copy of the findings which were delivered on 02/02/2021:**

Regarding allegation Staff mismanaged Resident’s medication:

On 01/27/2021 interviewed the Hospice Registered Nurse (RN)/ Case Manager and Hospice Social Worker (SW) that oversaw the care of Resident 1 (R1). SW stated: “felt like the staff were knowledgeable” and “never felt like anything was rushed or tried to be covered-up (by facility staff)”. Both Hospice staff had no concerns regarding abuse of R1. RN stated R1 “was placed on oxygen and (RN) did all the care and training of staff.” RN stated she “would be able to tell if oxygen level was low contingent on saturation rate which would have displayed low.” This means that if any staff member reduced the amount of oxygen R1 received she would have been able to observe the reduction in oxygen.

On 01/30/2021 LPA interviewed facility four (4) staff that were employees during November 2020 and provided services to R1. No staff witnessed or were aware of any abusive behavior. Staff 3 (S3) stated she received training on how to administer oxygen in the form of video instruction and physical instruction. S3 states Administrator Makayla would provide guidance in administering oxygen as well.

On 01/31/2021 LPA reviewed the following documentation as it relates to R1; Care Notes for November 2020, Medication Assistance Records (MAR) for November 2020. On the MAR anytime medication was not administered, it was due to one of the following reasons: Resident Refused and Hospice was notified, or all meds not given per hospice direction.

The allegation indicates that facility staff adjusted oxygen of R1. Document review, interviews with hospice nurse and facility staff revealed that medication (oxygen) was administered correctly under the guidance and training of a hospice nurse.

Based on interviews and observations LPAs determine that this allegation is UNFOUNDED at this time. This means that the allegation is false, could not have happened, and/or is without a reasonable basis.

A copy of this amended report was provided to Administrator Makayla White vie email. The original signature is on the hardcopy at Community Care Licensing (CCL) and the other copy is to be retained by the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021

LIC9099 (FAS) - (06/04)

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