374602369-11-12-2020-08-AS-JLOT-BVB2SJ-20201112163914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 11/12/2020
Date Signed: 11/12/2020 04:39:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 74	DATE:	11/12/2020
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Licensee, Dan Salceda		TIME COMPLETED:	04:40 PM

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	Licensing Program Analyst (LPA) Jennifer Lott, conducted an announced Case Management office visit. LPA identified herself to Licensee, Dan Salceda and discussed the purpose of their office visit. The purpose of LPA’s office visit was to discuss a death report received in our office on April 9, 2020, which indicated that resident #1 (R1) has passed away due to a fall. The investigation revealed that on or about April 6, 2020, R1 who suffers from a major neurocognitive disorder, was discharged from a skilled nursing facility, back to GLHM. Upon admission to GLHM, Staff #1 (S1) was provided R1’s discharge papers. Outside source records revealed that R1 was a fall risk, had fallen several times prior and thus required supervision, contact guard, touching and steadying while toileting. Interviews with staff and outside sources revealed that S1 advised facility staff that R1 was weak and unsteady and would require additional assistance, but was not told that stand assist was needed while toileting. Interviews with staff also revealed that R1 was placed in Assisted Living and not in the Memory Care Unit despite their medical diagnosis. Interviews with staff and outside sources also revealed that S1 was also informed by R1’s family that R1 would require additional assistance but the family was told that it would take several days to determine a care plan for R1. Interviews with S1 revealed that S1 did not read the discharge papers from the skilled nursing facility in order to determine R1’s new care needs. On this same day at or about 4:30 PM, Staff #2 (S2) discovered that R1 had fallen and was on the floor in their room. S2 notified Staff #3 (S3), who checked R1 for injury and assisted in getting R1 back to bed. R1 had not sustained injury nor did they have a complaint of pain. A fall mitigation plan still had not been developed for R1 despite the most recent fall.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jennifer Lott	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/12/2020

NARRATIVE

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Case Management Continued - Page 2

At approximately 8:30pm, R1 advised both S2 and S3 that they were feeling sick to their stomach. At or about 8:30 PM, R1 asked S2 to assist them to the bathroom as they felt as if they were going to vomit. Once the nausea subsided, R1 then asked S2 to assist them to the toilet. S2 seated R1 on the toilet, then left R1 alone in the bathroom to check on another resident two (2) doors down. Interviews with staff revealed that all staff caring for R1 that day knew that R1 was weak and unsteady but a care plan stating that R1 needed stand by assistance while toileting still had not been written.

At or about 8:40pm, S2 returned to check on R1. R1 was found on the floor of the bathroom with their head and upper extremity in the shower area, while their lower extremity was near the base of the toilet. R1 was unresponsive, had no pulse, and was not breathing. S2 then contacted S3 and S3 dialed 911 and with instruction from the operator, began administering CPR. Law Enforcement arrived on scene a several minutes later as well as paramedics and took over resuscitative measures (CPR). S1 presented paramedics with R1’s do not resuscitate (DNR) documents and they ceased any further life saving activities. R1 was pronounced deceased by paramedics on the scene. Death Certificate revealed that R1’s death was caused by a traumatic brain injury due to striking their head during a fall.

S1 admitted to not reading the discharge care plan instructions from R1’s skilled nursing facility. Therefore, S1 did not update R1’s appraisal, in writing, to include the changes in the care and supervision needed to ensure the health and safety of R1.

This agency has investigated the incident that occurred on April 6, 2020, which resulted in the death of R1. Based on review of facility records, outside source records, interviews with staff and outside sources, the preponderance of evidence standard has been met; therefore the licensee if found culpable of negligence which resulted in the fall that ultimately caused the death of R1. A deficiency is cited per California Code of Regulations, Title 22, Division 6, on the attached LIC 809D.

At this time, per Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted and a copy of this report, Appeal and Licensee Rights (LIC 9058 01/16), along with the Confidential Names (LIC 811) was provided to Licensee, Dan Salceda.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jennifer Lott	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/12/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 11/26/2020 Section Cited	1 2 3 4 5 6 7	Care of Persons with Dementia - ..."When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident." This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Licensee did not conduct a reappraisal when R1 was discharged from a SNF to GLHM. This poses an immediate health and safety risk in one (1) of 66 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jennifer Lott	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

LIC809 (FAS) - (06/04)

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