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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602062
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:29:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GOLDEN SUNSET RESIDENTIALFACILITY NUMBER:
374602062
ADMINISTRATOR:MIGUEL A MALONEFACILITY TYPE:
740
ADDRESS:7541 MILKY WAY POINTTELEPHONE:
(619) 794-2889
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Miguel MaloneTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced Case Management visit to discuss deficiencies discovered during a complaint investigation delivered on August 24, 2021. LPA was met by Caregiver, Perla Martinez, and was granted entry into the facility. LPA spoke with Administrator, Miguel Malone, by phone and discussed the purpose of the visit.

During a complaint investigation conducted by the Department, it was discovered that the licensee retained Resident #1 (R1), a resident with Diabetes. Review of records and interviews revealed that R1 was not able to perform their own glucose testing and was unable to administer their prescribed insulin injections. Investigative interviews revealed that staff who were not appropriately skilled professionals performed glucose testing for R1 and administered insulin injections to R1.

It was also discovered that there are two operational showers in the facility, but the facility is choosing to only use the shower in the shared bedroom. In doing so, staff and residents are using the shared bedroom as a passageway to the second bathroom.

Record review and interviews revealed that the licensee provided false training records for Staff #2-3 (S2-S3).

These deficiencies are noted on the attached LIC 809-D, and are cited in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with Mr. Malone and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2021
Section Cited

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DIABETES
The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by:
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Based on record review and interviews, the licensee retained R1, who was unable to perform their own glucose testing or administer their own insulin injections. Untrained staff, who were not appropriately skilled professionals, performed glucose testing and administered insulin injections to R1. This posed a potential health risk to R1.
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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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2021
Section Cited

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PERSONAL ACCOMMODATIONS AND SERVICES
No bedroom of a resident shall be used as a passageway to another room, bath, or toilet. This requirement was not met as evidenced by:
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Based on interview and LPA observations, the bathroom in bedroom #4 is used as the bathroom for resident showers. This poses a personal rights risk to residents in care.
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Type B
08/31/2021
Section Cited

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FALSE CLAIMS
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
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Based on record review and interview, the licensee provided false training records of initial training for S2 and S3. This posed a potential health and safety risk to four of four 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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