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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366427602
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:21:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
04/03/2024 and conducted by Evaluator Anna Fannell
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240403141835
FACILITY NAME:GOLDEN YEARS RESIDENTIAL CAREFACILITY NUMBER:
366427602
ADMINISTRATOR:ALEXANDRU POPESCUFACILITY TYPE:
740
ADDRESS:7890 SAN BENITO STREETTELEPHONE:
(909) 335-8335
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:6CENSUS: 2DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rosie Gaxiola - Care ProviderTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff did not ensure that resident was adequately fed.
Staff isolated resident in their room.
Staff did not ensure that resident's oral hygiene needs were met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegations. LPA met with care staff Rosie Gaxiola who was advised of the purpose of visit. The investigation consisted of interviews with relevant parties, and review of pertinent records. LPA was unable to interview Resident (R1).

Allegation 1: Staff (S1) did not ensure that R1 was adequately fed. Interviews with R1 representative revealed that they witnessed S1 provide food to R1 but would not provide assistance in feeding R1. Records revealed that R1 need maximum assistance with activities of daily living (ADLs). Interview with Administrator George Ene revealed that R1 was refusing to eat and was combative. However, records revealed that R1 was provided a solution for their behavior. Records also revealed that S1 was educated to assist R1 with eating. This allegation is substantiated.
Allegation 2: S1 isolated resident in their room. LPA interviewed R1 representative who stated that R1's door was closed when they arrived to visit. Records revealed that R1's bedroom door was closed when R1 is visited by other witnesses. This allegation is therefore substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna FannellTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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 56-AS-20240403141835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE
FACILITY NUMBER: 366427602
VISIT DATE: 04/10/2024
NARRATIVE
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Allegation 3: Staff did not ensure that resident's oral hygiene needs were met. Witness interviewed reveal that they observed R1's gums to be bleeding. Records revealed that R1 was instructed to provide oral care to R1. This allegation is therefore substantiated.

A complaint finding that the allegation is SUBSTANTIATED means that the allegation/s is/are valid as the preponderance of the evidence standard has been met. Refer to LIC809-D for deficiencies cited. An exit interview was conducted telephonically with Administrator Iren Creighton where this report, LIC809-D, and appeal rights were discussed.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna FannellTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20240403141835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE
FACILITY NUMBER: 366427602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2024
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating...
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Licensee shall read the CCR section cited, 87464, and provide a statement of understanding of the regulation. Licensee shall submit proof of correction no later than end of POC day.
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This requirement was not met as evidenced by:
Interviews and records reviewed revealed that R1 needed maximum assistance with ADLs, and although food was provided, assistance while R1 was eating was not provided as observed by witnesses. This poses as a potential health and safety risk to residents in care.
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Type B
04/16/2024
Section Cited
CCR
87705(b)(2)
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(b) In addition to the requirements as specified in Section 87208...the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior...
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Licensee shall review and re-evaluate their Dementia Care Plan. Licensee shall provide proof of review/acknowledgement and, as needed, provide a copy of the update Dementia Care Plan to the Regional Office no later than end of POC day.
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This requirement was not met as evidenced by:
Interviews and records reviewed revealed that R1 had behaviors commonly seen in persons with Dementia and staff would keep R1 in their room with their door closed to address these behaviors. This poses as a potential health and safety 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna FannellTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20240403141835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE
FACILITY NUMBER: 366427602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2024
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Licensee shall read the CCR section cited, 87465, and provide a statement of understanding of the regulation. Licensee shall submit proof of correction no later than end of POC day.
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This requirement was not met as evidenced by:
Interviews and records reviewed revealed that R1's gums were observed bleeding from poor oral care. This poses as a potential health and safety 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna FannellTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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
SAN BERNARDINO ASC, 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
04/03/2024 and conducted by Evaluator Anna Fannell
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240403141835

FACILITY NAME:GOLDEN YEARS RESIDENTIAL CAREFACILITY NUMBER:
366427602
ADMINISTRATOR:ALEXANDRU POPESCUFACILITY TYPE:
740
ADDRESS:7890 SAN BENITO STREETTELEPHONE:
(909) 335-8335
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:6CENSUS: 2DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rosie Gaxiola - Care ProviderTIME COMPLETED:
01:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide daily activities for resident.
Staff restrained resident at night.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegations. LPA met with care staff Rosie Gaxiola who was advised of the purpose of visit. The investigation consisted of interviews with relelvant parties, and review of pertinent records. LPA was unable to interview Resident (R1).

Allegation 1: Staff did not provide daily activities for R1. Interview with current residents and staff reveal that residents prefer to be on their own but may socialize in the common areas. Records revealed that R1 was observed with other residents socializing and watching television in the living room.
Allegation 2: Staff restrained resident at night. Interviews with current residents and staff deny that residents are restrained at any time. Interview with R1 representative revealed that they have not observed R1 restrained. Records reviewed do not show that R1 is restratined at any time.

Based on the available information, the complaint allegations are UNSUBSTANTIATED meaning that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted telephonically with Administrator Iren Creighton where this report was discussed and a copy was given to facility staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna FannellTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5