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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 02/14/2023
Date Signed: 02/15/2023 07:15:41 AM

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
10/14/2020 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20201014143359
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: 85DATE:
02/14/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator, Rocio GrandaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility changed resident's room accommodations without amending the admissions agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA gained access to the facility, met with Administrator, Rocio Granda and explained the purpose of the visit which was to deliver findings for the above allegation.

The Department’s investigation consisted of record reviews, interviews with staff, residents, and outside sources.

On October 14, 2020, it was alleged that the facility changed resident’s room accommodations without amending the admissions agreement. More specifically, it was alleged that on September 9, 2020 Resident 1 (R1) was on a leave of absence from the facility and upon return to the facility, R1’s personal belongings were moved to a different room without their knowledge.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
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 5
Control Number 08-AS-20201014143359
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: 02/14/2023
NARRATIVE
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Interviews conducted with staff and residents confirmed R1’s absence was due to being treated in a Skilled Nursing Facility (SNF). A review of facility records confirmed the location of R1’s room at the time of admission to the facility on July 16, 2020, had changed upon R1’s return from the SNF. Facility records also revealed R1 would be provided a 30-days written notice before substituting their room, unless R1 agreed to the request for a change, if it was required to fill a vacant bed, or the move was necessary due to an emergency. An Interview with the facility Administrator revealed there was no documentation of a room change addendum or a 30-day notice provided to R1.

The Department has investigated the allegation of facility changed resident’s room accommodations without amending the admissions agreement. Based on evidence obtained, the allegation is substantiated. A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited in accordance of California Code of Regulations, Title 22, Division 6 Chapter 8, and is listed on the 9099D.

An exit interview was conducted with Administrator, Rocio Granda and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/14/2020 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20201014143359

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: 85DATE:
02/14/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator, Rocio GrandaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
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9
Facility did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA gained access to the facility, met with Administrator, Rocio Granda and explained the purpose of the visit which was to deliver findings for the above allegation.

The Department’s investigation consisted of record reviews, interviews with staff, residents, and outside sources.

On October 14, 2020, it was alleged that facility did not safeguard resident’s personal belongings. More specifically, it was alleged that when resident 1 (R1) returned to the facility from a leave of absence, at a skilled nursing facility (SNF), their medication along with R1’s other various items were missing from their nightstand. Records reviewed revealed R1’s medications were prescribed and confirmed R1 could manage their own medication.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20201014143359
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: 02/14/2023
NARRATIVE
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However, interviews with facility staff could not confirm if medications had remained stored in R1’s room while being treated at a SNF. Records further reviewed, including R1’s list of personal inventory, did not include all of R1’s personal belongings that were alleged missing. Interviews with staff and residents were inconsistent and could not corroborate the allegation facility did not safeguard resident’s personal belongings.

The Department has investigated the allegation of facility did not safeguard resident’s personal belongings. Based on evidence obtained, including interviews and records reviewed, the above allegation is determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard.

An exit interview was conducted with Administrator, Rocio Granda and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20201014143359
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: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited
CCR
87507
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87507 Admissions Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by:

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Administrator stated they will have a Personal Rights training for all staff regarding communicating changes with residents in care and not touching residents personal property by an approved vendor. They will provide verification of the training to the Department by March 16, 2023.
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Based on interviews and records reviewed, Licensee did not notify R1 or amend the admission agreement when changing R1’s room. This posed a personal rights risk to 1 out of 75 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) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5