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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881309
Report Date: 04/25/2025
Date Signed: 04/25/2025 01:18:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230815163259
FACILITY NAME:GOLDEN HORIZON SENIOR CAREFACILITY NUMBER:
361881309
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:1524 S EUCLID AVETELEPHONE:
(786) 564-3771
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:22CENSUS: 22DATE:
04/25/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stephanie Morales- CaregiverTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not prevent residents from engaging in a physical altercation.
Resident sustained severe injuries due to staff neglect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Facility Caregiver Staphanie Morales. The investigation consisted of resident interviews, staff interviews, and record review.

For allegation, Staff did not prevent residents from engaging in a physical altercation:
Interviews with the clients and the staff revealed that on 8/7/2023 Resident R1 was physically assaulted by Resident R2. On 8/6/2023, Staff S1 was the only staff on duty at the facility as of 6:00 PM. S1 went to sleep around 10:00 PM on 8/6/2023 which left the residents in the facility unsupervised from 10:00 PM on 8/6/2023 to 1:00 AM on 8/7/2023. Around 1:00 AM, S1 was awoken by Resident R3 and informed there was an assault between R1 and R2. At this time, S1 walked into the living room and found R1 sitting on the couch covered in blood. S1 asked R1 what happened, S1 told R1 that S1 was attacked by R2 with a laundry basket.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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 3
Control Number 56-AS-20230815163259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309
VISIT DATE: 04/25/2025
NARRATIVE
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 S1 went into R1’s bedroom and found blood on the floor and a bloody cracked laundry basket on R1’s bed. S1 accessed R1 and called emergency services. Document review of a special incident report (SIR) dated 8/72023, stated that R2 hit R1 on the head with a laundry basket more than twenty (20) times. Additionally, there were four (4) incidents reported in May of 2023 between R1 and R2. During these incidents, R2 attempted to throw a water bottle at R1, R2 was upset that R1 was in R2’s way, R2 knocked R1’s hat off R1’s head, R1 accused R2 of throwing R1’s walker and hitting R1 on the head. No injuries were reported for the prior incidents. S1 stated that they kept a closer eye on R1 due to believing R1 was at risk. No additional means were made by the facility to ensure the safety of R1.,

For allegation, Resident sustained severe injuries due to staff neglect:

Medical record review of R1’s hospital records from 8/7/2023 revealed R1 sustained severe injuries due to the assault the occurred. R1 suffered from contusions and lacerations of the vertex of the head and the right parietal areas. R1’s wounds went down to the subcutaneous tissue.

Based on evidence obtained during the investigation, the two (2) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because of the preponderance of evidence the standard has been met. In addition, an immediate civil penalty is assessed for $500.00, per Health and Safety Code. In addition, an additional review is being conducted and additional civil penalty may be imposed per Health and Safety Code

During today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed and provided to Facility Caregiver Stephanie Morales, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230815163259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2025
Section Cited
HSC
87468.1(a)(3)
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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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement is not met as evidenced by:
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The licensee has agreed to read regulation 87468 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to send LPA a plan that explains how the facility staff will ensure the residents are safe and how their daily functions will be supervised to ensure their safety. POC is due by 4/28/2025.
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based on interview and document review, the licensee did not comply with the section cited above evidenced by not ensuring the resident was safe and free from abuse and intimidation which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to read regulation 87415 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed that moving forward the facility will staff an awake staff to supervise the residents. The licensee has agreed to send LPA a staff schedule that includes staff coverage for 24 hours a day, 7 days a week. POC is due by 5/2/2025.
Type B
05/02/2025
Section Cited
CCR
87415(a)(2)
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Night Supervision....(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency. (2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.

This requirement is not met as evidenced by:
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based on interview and document review, the licensee did not comply with the section cited above evidenced by not having an awake night staff on duty which poses an immediate health, safety, or personal rights risk to persons 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: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3