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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602062
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:14:49 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2020 and conducted by Evaluator Lizzette Tellez
COMPLAINT CONTROL NUMBER: 08-AS-20200228132855
FACILITY NAME:GOLDEN SUNSET RESIDENTIALFACILITY NUMBER:
374602062
ADMINISTRATOR:MIGUEL A MALONEFACILITY TYPE:
740
ADDRESS:7541 MILKY WAY POINTTELEPHONE:
(619) 564-2845
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: 4DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Miguel MaloneTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Licensee failed to administer medication as prescribed
Licensee failed to meet resident's oxygen needs
Licensee did not treat resident with dignity
Facility staff untrained
INVESTIGATION FINDINGS:
1
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3
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5
6
7
8
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10
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12
13
Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA was met by Caregiver, Perla Martinez, and was granted entry into the facility. LPA spoke with Administrator, Miguel Malone, via phone and discussed the purpose of the visit.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, review of records, and a tour of the facility. It was alleged that the Licensee failed to administer medication as prescribed to Resident #1 (R1). Mr. Malone was provided with LIC 811 – Confidential Names Form, in order to identify R1. Investigative interviews, record review, and LPA observations revealed that R1 was prescribed ten (10) routine, daily medications. Investigation revealed that staff relied on informal translations of physician’s orders for R1, which were incorrectly translated. Staff were not providing the correct dosage of four of ten medications, and were also not providing them at the correct frequency. The Department was unable to interview R1.

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 08-AS-20200228132855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/24/2021
NARRATIVE
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It was alleged that the Licensee failed to meet R1’s oxygen needs. Interviews with outside sources and staff revealed that on or about February 2020, the facility failed to maintain portable oxygen tanks for R1. A tour of the facility revealed that R1 had an oxygen concentrator for use in their bedroom. As R1 had run out of portable oxygen tanks, they were unable to leave their room until the tanks were replaced, as they required oxygen at all times. The Department was unable to interview R1.

It was alleged that the Licensee did not treat R1 with dignity. Interviews with outside sources and staff revealed that on multiple occasions, R1 had arguments with Staff #1 (S1) where S1 yelled at R1. Record review revealed R1 did not suffer from a major neurocognitive disorder, and was able to communicate their needs. The Department was unable to interview R1.

It was alleged that facility staff are untrained. Investigation revealed that staff typically work in two-week cycles. Interviews with staff yielded conflicting statements, and were inconsistent with training documentation provided by the Licensee. Interviews with staff revealed staff were not provided medication training, which was inconsistent with documentation provided. Based on the documentation that was provided, the hours and topics of training documented did not coincide with statements from staff.

The Department has investigated the above-mentioned allegations and has found that, based upon the evidence gathered during the investigation, the preponderance of the evidence standard has been met, and the allegations are valid. Therefore, these allegations have been deemed substantiated.

These deficiencies are noted on the attached 9099-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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20200228132855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87465(a)(5)
1
2
3
4
5
6
7
INCIDENTAL MEDICAL AND DENTAL CARE
1. Incidental Medical and Dental Care 87465(a)(5) - The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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R1 no longer resides at the facility.
IMMEDIATE RISK REMOVED PRIOR TO VISIT. Additionally, Licensee stated medication training refresher would be provided. Proof of training to be provided to CCL by 9/21/20.
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9
10
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Based on interviews and record review, staff did not assist R1 with taking 4 out of 10 medications as prescribed. This poses a potential health 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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20200228132855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87465(a)(2)
1
2
3
4
5
6
7
INCIDENTAL MEDICAL AND DENTAL CARE
The licensee shall provide assistance in meeting necessary medical and dental needs… This requirement was not met as evidenced by:
1
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3
4
5
6
7
R1 no longer resides in the facility. Licensee stated an addendum to the medication training would be provided regarding oxygen and supplies. Copy of the addendum to be provided to CCL by POC date.
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9
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11
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Based on interviews, staff did not ensure R1’s medical needs were met when the licensee did not ensure that R1 had a sufficient supply of oxygen tanks. This posed a potential health risk to R1.
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14
Type B
09/21/2021
Section Cited
CCR
87468.1(a)(1)
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7
PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES
To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee stated S1 would receive refresher training regarding personal rights, and provide proof of training by POC date.
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Based on interviews, staff did not accord R1 dignity when they yelled at R1 during a verbal argument. This posed a potential personal rights 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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20200228132855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
08/24/2021
Section Cited
HSC
1569.625(b)(1)
1
2
3
4
5
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7
STAFF TRAINING; LEGISLATIVE FINDINGS; CONTENTS
The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. This requirement was not met as evidenced by:
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Licensee stated S2 and S3 no longer work for the facility. Licensee states additional staff will be maintained to ensure staff receive required training hours prior to working independently. During today's visit, two staff and a trainee were onsite.
DEFICIENCY CLEARED PRIOR TO VISIT.
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Based on interviews and record review, S1 and S2 did not complete required 40 hours of training prior to working independently in the facility. 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
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2020 and conducted by Evaluator Lizzette Tellez
COMPLAINT CONTROL NUMBER: 08-AS-20200228132855

FACILITY NAME:GOLDEN SUNSET RESIDENTIALFACILITY NUMBER:
374602062
ADMINISTRATOR:MIGUEL A MALONEFACILITY TYPE:
740
ADDRESS:7541 MILKY WAY POINTTELEPHONE:
(619) 564-2845
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: 4DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Miguel MaloneTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee failed to follow resident's hospital discharge orders
Licensee failed to maintain required food supply
Licensee did not provide food of the quality necessary to meet the needs of the residents
Licensee did not provide food in the quantity necessary to meet the needs of the residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA was met by Caregiver, Perla Martinez, and was granted entry into the facility. LPA spoke with Administrator, Miguel Malone, and discussed the purpose of the visit.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, review of records, and a tour of the facility. It was alleged that the Licensee failed to follow Resident #2’s (R2) hospital discharge orders. Investigation revealed that R2 was admitted to the facility in October 2019, after a hip dislocation. R2, a resident with major neurocognitive disorder, was prescribed a hip brace for stability. Interviews with staff, outside sources, and R2 did not support the allegation. Interviews revealed R2 is assisted by staff with wearing the brace at all times, except to bathe and change clothing.


Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20200228132855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/24/2021
NARRATIVE
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3
4
5
6
7
8
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It was alleged that Licensee did not provide food in the quantity necessary to meet the needs of the residents. Investigation revealed that the facility provides three meals a day with snacks in between. During a tour of the facility, LPA observed a meal served and the portion size appeared to be adequate. Interviews with outside sources who have visited the facility did not yield concern regarding the quantity of foods served. The Department was unable to interview relevant residents due to their cognitive limitations, or not being available for interview. Resident records were reviewed and were not noted to require a special diet.

It was alleged that the Licensee failed to maintain required food supply. During a tour of the facility, a sufficient supply of perishable and non-perishable foods was observed. Interviews with staff and outside sources did not support the allegation. Groceries are purchased once per week. Interviews with staff and outside sources did not support the allegation. The Department was unable to interview relevant residents due to their cognitive impairment, or not being available for interview.

It was alleged that the Licensee did not provide food of the quality necessary to meet the needs of the residents, more specifically that there are highly processed foods served. Investigation revealed that the facility purchases food from grocery stores and warehouse stores. During a tour of the facility, a variety of fresh and frozen foods, including proteins, fruits, vegetables, and dry goods were observed. There were also various foods with residents’ initials or names on them. If a resident does not want the food that is served, then an alternative meal may be offered. Foods stored were not expired and did not appear to be of poor quality. The Department was unable to interview relevant residents due to their cognitive impairment, or not being available for interview.

This Department has investigated the above-mentioned allegations and has found that there is insufficient evidence to prove or corroborate the allegations. Therefore, these allegations have been deemed unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 7 of 7