<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 04/02/2024
Date Signed: 04/02/2024 05:42:37 PM

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
03/28/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240328101228
FACILITY NAME:GOLDEN LIVING HEALTH MANAGEMENT, INC.FACILITY NUMBER:
374602369
ADMINISTRATOR:ROCIO GRANDAFACILITY TYPE:
740
ADDRESS:3223 DUKE STREETTELEPHONE:
(619) 222-1109
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:113CENSUS: 91DATE:
04/02/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Business Office Manager, Monica CordovaTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medications not given as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Natasha Persaud and Ryan Fulton conducted an unannounced visit to commence a complaint investigation. LPAs met with Administrator, Rocio Granda and Business Office Manager, Monica Cordova.

During today's visit, LPAs briefly toured the facility, requested records, interviewed staff and residents. It was alleged that medications were not given as prescribed for Resident #1 (R1). It was reported the facility stopped dispensing medications to R1. R1’s Physician Report dated 02/12/24 showed the facility store and manage R1’s medications. A review of R1’s Medication Administration Record (MAR) dated 03/14/24 to 04/12/24 indicated medications were being dispensed to R1. However, the MARs also had missing signatures, which was a sign the medications were not given as prescribed. R1 was transported to the hospital on 03/26/24 for a medical condition. At the hospital, R1 was diagnosed with an allergy to a specific medication and provided with discharge documentation that reflected R1 had the new allergy. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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 5
Control Number 08-AS-20240328101228
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: 04/02/2024
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
Upon R1’s return, the facility received and reviewed the hospital documentation indicating the new allergic reaction to the exiting medication. Therefore, the facility should have discontinued the specific medication that caused the allergic reaction, removed the medication from the medication cart, and/or updated the MARs. Instead, the facility dispensed the medication causing the allergic reaction from 03/27/24 thru 04/01/24. Staff interviews confirmed they were aware the medication should have not been dispensed. However, staff stated R1 wanted the medication, therefore, it was dispensed to R1. Medications were not given as prescribed once the facility had knowledge to discontinue.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Business Office Manager, Monica Cordova whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names list to identify Resident #1]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240328101228
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: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2024
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated she will schedule medication training by POC due and implement a new medication policy and procedure to ensure medications are given as prescribed. In addition, proof of training will be provided within 2 weeks.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not give medications as prescribed to 1 out of 91 residents [R1] in care, which posed an immediate Health and Safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
03/28/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240328101228

FACILITY NAME:GOLDEN LIVING HEALTH MANAGEMENT, INC.FACILITY NUMBER:
374602369
ADMINISTRATOR:ROCIO GRANDAFACILITY TYPE:
740
ADDRESS:3223 DUKE STREETTELEPHONE:
(619) 222-1109
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:113CENSUS: 91DATE:
04/02/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Business Office Manager, Monica CordovaTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication error resulting in injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Natasha Persaud and Ryan Fulton conducted an unannounced visit to commence a complaint investigation. LPAs met with Administrator, Rocio Granda and Business Office Manager, Monica Cordova.

During today's visit, LPAs briefly toured the facility, requested records, interviewed staff and residents. It was alleged that there was a medication error resulting in injury for Resident #1 (R1). R1’s Physician Report dated 02/12/24 reflected the facility store and manage R1’s medications. A review of facility records indicated on 03/21/24, R1 was found on the floor. R1 was transported to the hospital and diagnosed with a closed head injury and contusions. R1’s Medication Administration Record dated 03/14/24 to 04/12/24 reflected the medications being dispensed were prescribed by R1’s physician. However, not all medications were given as prescribed but there was no evidence R1 fell as a result of the medications. Staff interviews revealed they dispensed R1’s medications. As staff was dispensing other resident medications, they heard a loud boom within five (5) minutes of dispensing R1’s medications. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240328101228
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: 04/02/2024
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
They discovered R1 on the floor and had R1 transported to the hospital. According to an internet search it takes approximately thirty (30) minutes for most medications to dissolve. Therefore, R1 would not have fallen within five (5) minutes of ingestion. R1’s interview revealed they took the medication and fell within minutes but did not believe it was a result of the medication.

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 was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Business Office Manager, Monica Cordova whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names list to identify Resident #1]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5