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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 05/20/2022
Date Signed: 05/20/2022 01:07:44 PM

Substantiated


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
06/16/2020 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20200616110557
FACILITY NAME:GOLDEN LIVING HEALTH MANAGEMENT, INC.FACILITY NUMBER:
374602369
ADMINISTRATOR:MNOYAN, MAYA S.FACILITY TYPE:
740
ADDRESS:3223 DUKE STREETTELEPHONE:
(619) 222-1109
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:113CENSUS: 82DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Monica Cordoba, Manager AssistanceTIME COMPLETED:
01:23 PM
ALLEGATION(S):
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Staff neglect resulting in serious injury.
Medication was not administered according to physician's orders.
Resident incurred unexplained bruising while in care.
Staff did not report an incident to resident's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA was granted entry into the facility and met with Monica Cordoba, Manager Assistance, and discussed the purpose of the visit. LPA also spoke with Rocio Granda, Administrator, over the phone.

The Department’s investigation consisted of record reviews, including medical and outside source records and interviews with staff and outside sources. On June 16, 2020, it was alleged that staff did not obtain medical treatment for Resident #1 (R1) to have the resident evaluated for injury after multiple falls occurred. It was further alleged that medication was not administered to R1 according to physician’s orders. It was also alleged that R1 incurred unexplained bruising while in care and that the fall incidents were not reported to R1’s responsible party.

[Continued on LIC9099-C, page 1 of 4]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 6
Control Number 08-AS-20200616110557
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 LIVING HEALTH MANAGEMENT, INC.
FACILITY NUMBER: 374602369
VISIT DATE: 05/20/2022
NARRATIVE
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[Continued from LIC9099-C, page 2 of 4]

Resident R1 was admitted to the facility on May 29, 2020. R1 had a diagnosis of Major Neurocognitive Disorder with agitation and mood swings. Pre-appraisal form dated May 28, 2020 stated R1 was ambulatory but “at risk of falls” and required staff assistance with transfers and with moving about the facility. Hospital discharge summary provided to the facility at the time of admission also stated that the resident was a “fall risk”; however, interviews and records determined a fall plan was not put in place until May 30, 2020, after two falls had already occurred.

Interviews and facility records showed on May 29, 2020, R1 fell out of their wheelchair and onto the floor at an unknown time and was found later by a caregiver (S1) at approximately 10:00PM. 911 was not called and R1 was not sent out to the hospital for further evaluation of possible injury. Interviews with multiple direct care staff corroborated that care staff were “not allowed to call 911” and only Medical Technicians (Med Techs) could do so. Facility records determined that no Med Techs routinely work the nocturnal shift. Interviews also revealed that there was no fall plan in place at this time and no fall prevention measures (e.g. lowered bed, fall mat) were yet implemented. On May 30, 2020, after a second unwitnessed fall at 1:30PM, the caregiver on duty (S2) placed the resident back in bed, and on charting notes claimed the resident stated they had no pain. No additional assessment was done to check for possible injury.

The next morning on May 31, 2020, the resident was complaining of pain to their lower back and legs to multiple caregivers. Over the next several days, R1 verbally expressed pain on multiple occasions, including while staff provided direct incontinence care to this resident. During this time, R1 was briefly sent out to the emergency room twice for an unrelated condition that did not require medical treatment. Care staff (S3) described R1 as being “in serious pain” and noted R1 would grab tightly onto caregiver’s hands during brief changes. Another staff (S4) said R1 would point to both legs and say that their legs hurt. Multiple staff statements acknowledged R1’s comments were reported and elevated to the administrator, but staff were advised to administer over-the-counter pain medication (Tylenol), and not send R1 to the hospital. Interview with R1’s primary care physician (PCP), revealed he was not contacted by the facility to report the falls and resultant pain symptoms as a change of condition. Interviews with R1’s responsible party revealed the facility did not notify R1’s responsible party about the fall incidents.

[Continued on LIC9099-C, page 2 of 4]
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20200616110557
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 LIVING HEALTH MANAGEMENT, INC.
FACILITY NUMBER: 374602369
VISIT DATE: 05/20/2022
NARRATIVE
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[Continued from LIC9099C, page 3 of 4]

On June 3, 2020, R1 was found on the floor by staff (S6) at approximately 6:00AM after a third unwitnessed fall. Staff noted R1 as being without visible injury and administered medication for R1’s anxiety. No additional evaluation was conducted, and facility did not summon 911 or contacted the PCP to get R1 evaluated by a medical professional. On June 6, 2020, while being voluntarily relocated to a new residential care facility, R1 complained of pain to their left hip and was observed by an outside source as showing extreme physical discomfort and requiring a two person assist from their wheelchair. R1 was immediately transported by ambulance to the hospital and then medically assessed as having a left hip fracture. Medical records confirmed the acute fracture had occurred recently, while R1 was residing at the facility. R1 subsequently had surgery for the hip fracture and was discharged from the hospital two weeks later, on June 21, 2020.

It was also alleged that R1 incurred unexplained bruising in care. Interviews and records review confirmed that R1 was observed by multiple outside sources on June 6, 2020 as having a visible bruise on their chin, as well as bruising on their left shoulder which facility staff could not explain. The location of the bruising appeared to be consistent with the resident’s falls but had not been documented by facility staff or reported to the resident’s responsible party.

It was further alleged that medication for R1 was not administered according to physician’s orders. Record reviews confirmed R1 had a diagnosis of Major Neurocognitive Disorder with agitation and mood swings; however, the facility accepted this resident on May 29, 2020 with no medications. Staff did not assist or make arrangements to ensure that R1’s prescribed medications were immediately obtained to meet the resident’s care needs. R1’s medications were not available at the facility until June 1, 2020, so no prescribed medications were given to R1 for 3 days, including psychotropic medications. Facility medication records were not kept to document dosages of over-the-counter pain medication given to R1 by staff, and the investigation could not determine how the anxiety medication was obtained. Interview statement by a skilled medical professional stated that due to the resident’s medical condition, the facility should not have accepted R1 into the facility without their medications.

[Continued on LIC9099-C, page 3 of 4]
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20200616110557
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 LIVING HEALTH MANAGEMENT, INC.
FACILITY NUMBER: 374602369
VISIT DATE: 05/20/2022
NARRATIVE
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[Continued from LIC9099-C, page 4 of 4]

This Department has investigated the allegations noted above. The Department has found that based upon record review and interviews gathered during the investigation, the preponderance of the evidence standard has been met. Therefore, these allegations are deemed substantiated. An immediate civil penalty in the amount of $500 is being assessed today and per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

The deficiencies are noted on the attached LIC9099-D form and are cited in accordance with the California Code of Regulations, Title 22. A copy of this report along with Licensee/Appeal Rights, LIC421IM were provided to Monica Cordoba, Manager Assistance, at the conclusion of the visit, and their signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20200616110557
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 LIVING HEALTH MANAGEMENT, INC.
FACILITY NUMBER: 374602369
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2022
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement was not met as evidenced by:
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Licensee will provide proof that progress has been made in scheduling an outside vendor for staff training. Licensee will contact LPA by end of business day of POC date to provide proof that scheduling has been made or attempted.
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Based on interviews and medical records review, licensee did not telephone 911 to obtain medical treatment for R1 after unwitnessed falls that resulted in serious bodily injury (hip fracture). This posed an immediate health risk to one of 82 residents in care.
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Type B
05/23/2022
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Licensee will conduct internal training and provide proof to LPA. Proof will consist of training content and signature of staff attesting to training.
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Based on interviews and records review, licensee did not assist R1 with prescribed medications upon admission to the facility. This posed a potential safety risk to one of 82 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: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 08-AS-20200616110557
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 LIVING HEALTH MANAGEMENT, INC.
FACILITY NUMBER: 374602369
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2022
Section Cited
CCR
87466
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87466 Observation of the Resident: ...residents are...observed for changes in physical...functioning... When changes …are observed, ...changes are documented and brought to the attention of…responsible person. This requirement was not met as evidenced by:
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Licensee will conduct internal training and provide proof to LPA. Proof will consist of training content and signature of staff attesting to training.
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Based on interviews and records review, licensee did not notify R1’s responsible party after R1 incurred multiple falls. This posed a potential health risk to one of 82 residents in care.
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Type B
06/20/2022
Section Cited
CCR
87464(d)
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87464(d) Basic Services: …if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal…
This requirement was not met as evidenced by:
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Licensee will conduct internal training and provide proof to LPA. Proof will consist of training content and signature of staff attesting to training.
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Staff did not provide assistance with R1’s fall risk needs identified in pre-admission appraisal, resulting in bruising due to falls. This posed a potential safety risk to one of 82 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: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6