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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602062
Report Date: 09/03/2021
Date Signed: 09/03/2021 11:59:09 AM



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
06/23/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210623133213
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: 5DATE:
09/03/2021
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Caregiver Alberto "Albie" Lopez Zaragoza and Administrator Miguel "Michael" MaloneTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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-Lack of supervision by facility staff.
-Facility staff did not meet resident needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Complaint Visit to deliver findings regarding the above allegations. LPA identified himself to and was granted entry by Caregiver Maria Gonzalez. LPA then met with and discussed the purpose of the visit with Caregiver Alberto "Albie" Lopez Zaragoza. During the visit, Administrator Miguel "Michael" Malone joined LPA by phone conference.

The Department’s investigation consisted of a review of facility administrative records and resident care records. Staff and outside sources were also interviewed. It was alleged that on the morning of 06-22-2021, Staff #1 (S1), who was the only caregiver present at the facility, fell asleep on the job, leaving Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4) unsupervised. [See LIC 811 Confidential Names List for a description of S1]. It was also alleged that during the time S1 was asleep, residents did not receive required help with their care needs. Specifically, R1 said they were “scared” and hungry, R2 said they had not seen a caregiver recently, and R3 said they were thirsty and could not remember when they last ate. [CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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 3
Control Number 08-AS-20210623133213
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: 09/03/2021
NARRATIVE
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[CONTINUED FROM LIC 9099]

A work schedule and interviews of multiple staff corroborate that S1 was the only employee present during the timeframe of the allegation, and that they fell asleep in a vacant bedroom. (Attempts to reach S1 by phone were unsuccessful, so LPA was unable to ask them how long they were asleep for. However, an outside source stated S1 confessed to being asleep from around 8:00 AM to 10:00 AM.) S1 reported the incident to the facility administrator the same day (who provided verbal corrective counseling), and to one additional supervisor. Both supervisors said: a) aside from 06-22-2021, there were no prior known incidents of S1 or any other staff falling asleep on the job, b) the typical caregiver shift is 12 hours long, which remains appropriate to the stamina level of the staff (which was corroborated by interviews of 2 of 2 additional caregivers), and c) S1 slept poorly the prior night due to a personal issue, but S1 did not call off for their shift or ask for help. S1 voluntarily resigned their position less than a week after the incident.

Staff interviews, care records, and LPA’s observations corroborate that R1, R2, R3, and R4 all had dementia and could not safely leave the facility unassisted per their respective physicians, yet R1 answered the doorbell and opened the front door while S1 remained asleep. Additionally, all residents required hands-on assistance with meal preparation, transferring, restroom/continence care, bathing, dressing, and medication management. Additionally, R2 had a urostomy bag requiring routine emptying, while R3 was wheelchair-bound and needed verbal cues to eat. The above needs could not be met during the period of time when there was no awake staff on duty.

Based on observation, interviews, and reviewed records, a preponderance of evidence exists to substantiate both allegations. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction and an exit interview was conducted with Lopez Zaragoza and Malone, to whom a copy of this report, the LIC 811, and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210623133213
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: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2021
Section Cited
CCR
87411(a)
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Personnel Requirements – General: “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This requirement is not met as evidenced by:
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Administrator provided verbal corrective counseling to S1 on 06-22-2021. S1 resigned after 06-26-2021. Administrator will retrain remaining staff on care and supervision and submit a sign-in sheet to LPA by the POC due date.
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Based on interviews, the licensee did not employ competent staff to provide the services necessary to meet resident needs for 4 of 4 persons in care [R1, R2, R3, and R4], which posed a potential safety or personal rights risk to persons in care.
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Type B
10/02/2021
Section Cited
CCR
87464(f)(4)
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Basic Services: “Basic Services shall at minimum include: Personal assistance and care as needed by the resident…with those activities of daily living such as dressing, eating, bathing, and assistance with taking prescribed medications…” This requirement is not met as evidenced by:
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Administrator provided verbal corrective counseling to S1 on 06-22-2021. S1 resigned after 06-26-2021. Administrator will retrain remaining staff on care and supervision and submit a sign-in sheet to LPA by the POC due date.
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Based on interviews and record review, the licensee did not provide personal assistance and care as needed to 4 of 4 persons in care [R1, R2, R3, and R4], which posed a potential health 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.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3