374602369-2-23-2024-08-AS-JLOT-D2TSRA-20240226130559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:58:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
10/06/2020 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20201006111840

FACILITY NAME:	GOLDEN LIVING HEALTH MANAGEMENT, INC.		FACILITY NUMBER:	374602369
ADMINISTRATOR:	MNOYAN, MAYA S.		FACILITY TYPE:	740
ADDRESS:	3223 DUKE STREET		TELEPHONE:	(619) 222-1109
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92110
CAPACITY:	113	CENSUS: 89	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Mina Ramirez, Caregiving Supervisor		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff failed to reposition resident.
Facility did not maintain resident's room temperature within regulation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to conduct interviews, collect records, and deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Mina Ramirez, Caregiving Supervisor.

On 10/6/2020 it was alleged that facility staff failed to reposition a resident, and did not maintain a resident's room temperature within regulation. The Department’s investigation consisted of a virtual and unannounced facility visit, interviews with facility staff, outside sources, records review, and LPA direct observations.

Regarding the allegation, "Facility staff failed to reposition resident", it was alleged that Resident 1 (R1) suffered pressure wounds due to staff not turning them in regular intervals. Staff interview revealed that R1's condition rose to a level of care that the Licensee could no longer provide; the issue was elevated to management for R1 to receive a higher level of care. Staff interview further revealed that staff attempted to reposition R1, but R1's Responsible Party refused to allow repositioning during the day, which further exacerbated the developing pressure wounds. (Continued on LIC9099 p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201006111840

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOLDEN LIVING HEALTH MANAGEMENT, INC.	FACILITY NUMBER: 374602369
	VISIT DATE: 02/23/2024

NARRATIVE

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(Continued from LIC9099 p.1)

Records review revealed that R1 had ongoing issues with their incontinence equipment, which resulted in R1's skin being exposed to moisture for extended periods of time, which was known to exacerbate skin breakdown. Records review showed that staff monitored R1's skin condition daily and elevated the issue to R1's physician, Responsible Party, and Home Health agency.

Outside source interview did not corroborate the allegation, informing that they had no knowledge of the accusation or issue at the facility.

R1 was unable to be interviewed for the investigation.

Regarding the allegation, "Facility did not maintain resident's room temperature within regulation", it was alleged that the Licensee did not act when R1's room was observed to be of high temperature.
Staff interview revealed that R1's Responsible Party would regularly increase the temperature of R1's room by turning on the room heater plus an additional personal heater, and place extra blankets on top of R1. Staff interview further revealed that staff attempted to turn off the heaters and remove the blankets, and open the windows in R1's room to cool it down. Staff interview further revealed that staff observed R1 to show signs of being too hot, such as visibly sweating, and communicated to R1's Responsible Party that R1 was too hot. Additional staff interviews revealed that on hot days staff would open windows and corridors throughout the facility for airflow, maintaining a comfortable temperature.

Outside source interview revealed observations of staff placing a fan in R1's room to lower the temperature. Additional outside source interviews did not corroborate the allegation, informing no knowledge of the accusation or issue at the facility.

Review of temperature records on the day in question produced varied results. Almanac.com showed that the temperature range on the day in question was between 66.9 and 97.0 degrees Fahrenheit; farmersalmanac.com showed a temperature range between 68.0 and 88.9 degrees Fahrenheit. No records were found to confirm the temperature of R1's room the day in question. As such, no evidence was found to corroborate that the Licensee did not maintain R1's room within regulation. No records were found to indicate that the facility exists in an extreme temperature area. (Continued on LIC9099 p.3)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201006111840

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOLDEN LIVING HEALTH MANAGEMENT, INC.	FACILITY NUMBER: 374602369
	VISIT DATE: 02/23/2024

NARRATIVE

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(Continued from LIC9099 p.2)

During an unannounced facility visit, LPA directly observed R1's former room, which was on the first floor of the building. LPA's observations corroborated staff statements regarding the ability to individually heat the room via heater. LPA observed windows in the room that could be opened for airflow, and also observed other resident rooms with open screen doors and/or windows for temperature preference.

R1 was unable to be interviewed for the investigation.

Based on interviews, direct LPA observations and records review, The investigation did not yield a preponderance of evidence to conclude that facility staff failed to position resident, and facility did not maintain resident's room temperature within regulation. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Mina Ramirez, Caregiving Supervisor, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

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