374602369-5-2-2024-08-AS-LTEZ-D5QQ8E-20240529115637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:53:02 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
08/18/2021 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20210818160505

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: 92	DATE:	05/02/2024
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Administrator, Rocio Granda		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulted in resident sustaining injury

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above-mentioned allegation. LPA met with Administrator, Rocio Granda.

During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged lack of supervision resulted in Resident #1 (R1) sustaining injury. It was reported Resident #2 (R2) pushed R1 down resulting in a fractured hip. R1’s Physician’s Report dated 02/03/15 indicated R1 had a Major Neurocognitive Disorder, was ambulatory, able to handle their own activities of daily living, and did not have aggression. R2’s Physician’s Report dated 06/12/21 indicated R2 had a Major Neurocognitive Disorder with behavioral disturbances but was not aggressive and required assistance with all activities of daily living. R2’s Preplacement Appraisal dated 06/29/21 acknowledged R2 had a Major Neurocognitive Disorder with behavioral disturbances. Continued on an LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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-20210818160505

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: 05/02/2024

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

On 8/17/2021 during dinner time, two (2) staff members were present in the dining room along with other residents to include R1 and R2. Staff interviews confirmed R1 and R2 did not have any contact with each other during dinner time. While staff were assisting the residents, R1 went to use the restroom. R2 did not want to sit nor eat and started to walk around in the dining room area. Staff observed R2 pushed R1 from behind, R1 fell to the ground. R1 complained of leg pain, and R2 started banging their own head against the wall. Staff called for assistance, then the Police and Paramedics arrived. Both R1 and R2 were transported to the hospital for evaluation and treatment. At the hospital, R1 was diagnosed with a fractured hip and received surgery.

R1 resided at the facility from 06/29/2021 to 8/17/2021. Facility records showed R2 started to show aggressive behavior towards other residents and staff as early as 7/4/2021. The administrator’s interview revealed they were looking for placement as R2 required a higher level of care. The administrator also indicated not being aware of the aggression upon admission and was not notified by R2’s responsible party there was any aggression to be addressed. Staff also reported they made accommodations to work and assist R2 while they were living at the facility. Facility records showed staff documented all incidents and the administrator attempted to find another placement for R2. The incident was observed by a staff member. Therefore, there was no lack of supervision resulting in the incident.

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 03/22) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Residents 1-2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2