374602369-4-5-2023-08-AS-LTEZ-CQTRDE-20230412125547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 04/05/2023
Date Signed: 04/05/2023 05:41:19 PM

Unsubstantiated

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
07/01/2022 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20220701092311

FACILITY NAME:	GOLDEN LIVING HEALTH MANAGEMENT, INC.		FACILITY NUMBER:	374602369
ADMINISTRATOR:	ROCIO GRANDA		FACILITY TYPE:	740
ADDRESS:	3223 DUKE STREET		TELEPHONE:	(619) 222-1109
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92110
CAPACITY:	113	CENSUS: 85	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Business Manager, Monica Cordoba		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following COVID-19 guidelines

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Natasha Persaud concluded the complaint investigation regarding the above mentioned allegation. LPA met with Business Manager, Monica Cordoba.

During the investigation, the facility was briefly toured, records requested, and interviews conducted with staff and outside sources. It was alleged, the facility was not following Covid-19 guidelines. It was reported the facility did not notify a visitor that came into contact with a resident that contracted Covid-19. Outside source interviews revealed on 06/27/22, a family member visited Resident #1 (R1) at the facility. On 06/29/22, R1 was not feeling well and presented with a fever. Therefore, the facility contacted 911 and had R1 transported to the hospital. R1 was diagnosed at the hospital with Covid-19 on 06/29/22. The administrator’s interview revealed R1 did not present with symptoms prior to 06/29/22. The administrator confirmed notifying R1’s responsible party that R1 was Covid-19 positive as outlined in their Mitigation Plan. R1’s responsible party’s interview confirmed they were notified of R1’s positive Covid-19 case. R1’s responsible party also stated they did not contact any family members to make them aware due to not having communication with them. Continued on an LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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 2

Control Number 08-AS-20220701092311

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: 04/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The facility has a visitor sign-in log. The administrator explained they did not review the visitor log, as they followed the guidelines of notifying the responsible party and R1’s physician. The Mitigation Plan and Provider Notification Information (PIN) 22-04 ASC indicated to document the individual’s name and contact information upon entering the facility for possible contact tracing. The Mitigation Plan and/or PIN does not have a requirement for contact tracing. There was no indication R1 was positive with Covid-19 on 06/27/22 as there were no present symptoms when the family member visited. Outside source interviews confirmed R1’s family member that visited R1 did not contract the virus and was not in danger. The facility uses the required Identification and Emergency Notification (IEN) form which identifies the responsible party. A review of R1’s IEN indicated R1’s responsible party was listed and there were no family members listed. The administrator followed the Covid-19 guidelines by notifying the appropriate parties outlined in their Mitigation Plan.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation is deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Business Manager, Monica Cordoba whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2