374602369-7-21-2023-08-AS-IESA-CUA5LE-20230731200300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 07/21/2023
Date Signed: 07/21/2023 04:45:52 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
04/07/2021 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20210407085800

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: 89	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Administrator, Rocio Granda		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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-Resident developed multiple pressure injuries while in care due to neglect
-Facility staff did not arrange medical care
-Facility staff did not observe change in the resident's condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above mentioned allegations. LPA met with Administrator, Rocio Granda.

During the investigation, the facility was toured, records requested, and interviews conducted with staff, residents, and outside sources. It was alleged Resident #1 (R1) developed multiple pressure injuries while in care due to neglect on or around 04/2021. R1’s Physician's Report dated 07/14/2020 indicated a special diet of Controlled Carbohydrate diet for diabetes; Bladder impairment; History of skin breakdown of rashes; Ambulatory and Independent with transfers. R1’s Physician’s Report dated 11/09/21 indicated a history of skin breakdown to bilateral posterior thighs, venous stasis ulcers. It also reflected R1 was non-ambulatory, in fair health status and able to feed and toilet themselves as well as handle their own cash resources. R1 did not have pressure injuries, they had venous stasis wounds. Continued on an LIC 9099.

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: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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-20210407085800

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: 07/21/2023

NARRATIVE

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According to the Mayo Clinic, a venous stasis wound, also known as venous ulcer, is due to abnormal vein function. Symptoms include a red, irritated skin rash that develops into an open wound. An Internet search revealed venous skin ulcers are caused by poor circulation in the legs caused by damaged valves that prevent blood from flowing the wrong way, allowing blood to pool in the legs. Pressure ulcers, on the other hand, are caused by sustained pressure on an area of the body, which cuts off blood flow.

The wounds were initially documented by the hospital on 01/18/21 and the wounds are still currently being treated as of July 2023. A review of facility records reflected on 02/16/2021 resident had an odor coming from the wound, so the facility sent R1 out for medical treatment. The hospital prescribed an antibiotic but R1 refused the medication and returned without any new orders, administrator was concerned as the leg was getting worse. The administrator’s interview revealed she was working on obtaining a Skilled Nursing Facility (SNF) for R1, so that R1 could receive wound care daily. However, R1’s medical insurance did not cover SNFs. On 02/16/21, the administrator and R1’s Primary Care Physician (PCP) were responding via text message. The PCP documented that the leg was getting worse but not due to an infection, the tissue was literally starving for oxygen and was poorly healing. PCP also documented there was no cure or medication, other than multiple daily wound care, hence the attempt to place R1 into a SNF. The administrator responded that the resident was not receiving sufficient care from Home Health (HH) and requested an order be sent to them for an increase of three times a week for wound treatment, explaining they were trying to help R1.

Medical Records dated 01/18/21 documented a diagnosis of venous stasis dermatitis and non-healing posterior calf ulcers. There were multiple HH agencies involved with R1’s care. HH medical records reflected R1 had four wounds with an onset of 03/01/21. Medical Records dated 04/01/21 reflected both leg ulcers, were chronic, not appearing newly infected, and similar to admission to hospital on 02/25/21-02/26/21. Facility records indicated on 04/01/23 around 5:30pm R1 was confused, unable to hold anything, and had numb fingers. R1 initially refused to go to the hospital, once advised by staff. On 04/01/23 around 7:18pm, staff were able to convince R1 to go to the hospital. Hospital records reflected R1 was admitted on 04/01/23 for weakness/difficulty ambulating with large non-healing ulcers on both legs. The administrator’s interview revealed R1 was offered a diabetic menu at the facility. However, R1 went out into the community and bought candy and chocolates, which have been observed in R1’s room.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210407085800

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: 07/21/2023

NARRATIVE

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R1’s interview revealed being non-compliant with wound care instructions, as they were responsible for their own wound care when HH was not present. R1 stated the wounds began in January 2021 due to their diabetes, poor health, and medical conditions. R1 confirmed the facility told them they cannot assist with wound care, which was why the facility was always telling R1 to go to the hospital when there was an issue with the wounds. R1 explained it was difficult going to hospital because their HH services were interrupted each time and they were provided a new HH upon return. There were so many HH agencies involved, the care continuously changed. R1 also explained the wounds were painful when changing the dressing. Therefore, R1 would not change the dressing, even when necessary, which caused the wounds to progress. R1 would wait for HH to arrive a day or two later to receive wound care. Medical records dated 02/21/21 indicated R1 was in a lot of pain and noted not wearing their leg wraps. R1 reported they took them off, as they didn't feel good. Medical records dated 02/10/21 identified R1 had high salt and simple sugar foods in their room that they snacked on. Also, on 02/10/21, the physician agreed R1 needed a SNF placement to help with wound care as the assisted living could not help in that area. R1 admitted the facility took really good care of them and were constantly trying to send R1 out to the hospital when there was pain. Even though the wounds developed at the facility, it was not due to neglect as R1 was admitted to the facility in July 2020 and was self-sufficient with their own care. Also, R1 was receiving wound care from HH. In addition, R1 was non-compliant with HH instructions.

It was also alleged, the facility did not arrange medical care and did not observe a change in the resident's condition in April 2021 for R1. A review of facility records indicated on multiple occasions that the facility recommended R1 to go to the hospital but R1 refused. Facility records indicated on 04/01/23 around 5:30pm R1 was confused, unable to hold anything, and had numb fingers. R1 refused again to go to the hospital, once advised by facility staff. On 04/01/23 around 7:18pm, staff were able to convince R1 to go to the hospital. Medical records confirmed R1 was admitted on 04/01/23 for weakness/difficulty ambulating with large non-healing ulcers on both legs. Staff interviews revealed R1 told them they do not like going to the hospital for medical attention due to extreme pain when the wounds were unwrapped.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210407085800

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: 07/21/2023

NARRATIVE

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Resident interviews confirmed they refused seeking medical treatment due to pain from wound exposure in the hospital. R1 also stated they refused medical treatment due to Home Health services were interrupted each time they go to the hospital. The administrator told R1’s PCP back on 02/16/21 that R1 was not receiving sufficient care from home health and a skilled nursing facility may be better suited. PCP attempted to assist with an order to get R1 into a SNF but R1’s medical insurance was not accepted at the SNFs. Medical records indicated R1 did not keep their legs wrapped as instructed or follow a diabetic diet as required. R1 has a history of non-compliance. Once the facility was made aware on 04/01/21 that R1 wasn’t feeling well they attempted to have R1 sent to the hospital for evaluation but R1 refused until later that evening. The facility did seek timely medical treatment for R1 and had no control over R1 refused to be evaluated by the hospital since this was R1’s personal right.

The ulcers were noted as chronic venous stasis ulcers, which were not a new condition. R1 had been receiving wound care as of 01/2021. On 04/15/21, the facility documented they were waiting for a discharge date from the hospital to obtain a new physician’s report and the reappraisal needed to be updated regarding wound care and mental health. R1’s interview revealed they were made aware by the facility to go to the hospital when the wounds were not well, as the facility was not allowed to provide wound care. R1’s wounds had been ongoing along with wound treatment by a Home Health agency. The administrator’s interview revealed that they were always encouraging R1 to seek medical treatment for their wounds as the HH was not providing sufficient care. R1’s interview confirmed R1 was non-compliant with wound care, which caused the wounds to progress. The facility continued to advise R1 to seek medical treatment. Facility records reflected documentation from the Administrator revealing a change in condition occurred. The administrator’s interview revealed the change in condition was not physical but mental. The administrator completed a new resident appraisal and later obtained a new physician’s report.

Based on interviews conducted, and records reviewed, the investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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