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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366402276
Report Date: 04/11/2022
Date Signed: 06/24/2022 09:58:35 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220302123752
FACILITY NAME:GOLDEN HOME CARE CENTERFACILITY NUMBER:
366402276
ADMINISTRATOR:ISAI, LETITIAFACILITY TYPE:
740
ADDRESS:12839 CYPRESS STREETTELEPHONE:
(909) 570-4237
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:4CENSUS: 4DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Licensee/Administrator Letitia IsaiTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident fell while in care.
Facility has inappropriate locking devices on resident's bedroom door.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit 04/11/2022 at 09:15 AM to deliver the findings for the above allegations. LPA Brown was greeted and granted entrance to the facility by Licensee/Administrator Letitia Isai. LPA Brown explained the purpose of today's visit.

The investigation consisted of file review, observation, and interviews with relevant parties. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The first allegation indicates resident fell while in care. LPA Brown conducted interviews with resident, staffs and hospice nurse. Resident, staffs and hospice nurses interviews indicated that resident fell while in care last 02/22/2022. Also, Hospice Care Nurse indicated that Administrator Isai reported last 02/24/2022 that R1 fell last 02/22/2022, and unable to determine when R1 fell.

**** Continuation in LIC9099C ****



Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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 18-AS-20220302123752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276
VISIT DATE: 04/11/2022
NARRATIVE
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Interview with S1 indicated S1 saw scratch on R1’s forehead while interview with R2 indicated that R2 saw blue marking on R1’s forehead the morning of 02/23/2022. Both S1 and R2 indicated that they did not witness R1’s fall. LPA Brown was not able to corroborate the allegation that resident fell while in care.

The second allegation indicates facility has inappropriate locking devices on residents’ bedroom door. LPA conducted interviews with resident, staffs and hospice care nurses. Resident, staffs and hospice nurses interviews indicated that the facility do not have inappropriate locking devices on residents room. LPA Brown was not able to corroborate the allegation that the facility has inappropriate locking device on residents’ room.

Therefore, the allegation resident fell while in care (allegation #1) and facility has inappropriate locking devices on residents’ bedroom door (allegation #2) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC9099) was discussed and provided to Licensee/Administrator Letitia Isai.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20220302123752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/12/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee stated that they will replace all residents room door knobs and will submit proof of purchase/installation to LPA Brown by POC due date.
Licensee already replaced all residents room door knob during the visit, POC cleared.
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Based on observation, interview and record review, the Licensee did not comply by having resident 1 door knob in disrepair due to being difficult to open which poses an immediate Health, Safety or Personal Rights risk to residents in care.
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Deficiency Dismissed
Type B
04/18/2022
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven ...
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Licensee stated to report all incidents at the facility to CCLD. Also, Licensee will submit Statement of Understanding to 87211 Reporting Requirements (a)(1) to LPA Melody Brown by POC due date.
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Based on observation, interview and record review, the Licensee did not comply by not reporting the incident that resdient 1 fell last 02/22/20022 to Community Care Licensing Department (CCLD) which poses a potential risk to resident 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2022 and conducted by Evaluator Melody Brown
COMPLAINT CONTROL NUMBER: 18-AS-20220302123752

FACILITY NAME:GOLDEN HOME CARE CENTERFACILITY NUMBER:
366402276
ADMINISTRATOR:ISAI, LETITIAFACILITY TYPE:
740
ADDRESS:12839 CYPRESS STREETTELEPHONE:
(909) 570-4237
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:4CENSUS: 4DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Licensee/Administrator Letitia IsaiTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff locks resident in room for extended periods of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit 04/11/2022 at 09:15 AM to deliver the findings for the above allegation. LPA Brown was greeted and granted entrance to the facility by Licensee/Administrator Letitia Isai. LPA Brown explained the purpose of today's visit.

The investigation consisted of file review and interviews with relevant parties. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The allegation indicates staff locks resident in room for extended periods of time. LPA conducted interviews with residents and staffs. Residents and staffs interviews indicated that staff do not lock resident in room for extended period of time. LPA Brown was not able to corroborate the allegation of staff locking resident in room for extended periods of time. Therefore, the allegation is UNSUBSTANTIATED.

**** Continuation in LIC9099C ****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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 18-AS-20220302123752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276
VISIT DATE: 04/11/2022
NARRATIVE
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 A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted where this report (LIC9099) was discussed and provided to Licensee/Administrator Letitia Isai.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5