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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 11/29/2022
Date Signed: 11/29/2022 04:56:36 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
09/19/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20220919175153
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: 83DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Care Coordinator, Perla BarraganTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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-Facility staff are not giving resident medication as prescribed
-Licensee did not maintain resident's room in a clean, safe, or sanitary condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude a complaint investigation. LPA identified herself and discussed the allegations mentioned above with

During the investigation, the facility was briefly toured, records requested, and interviews with staff, residents and outside sources. It was alleged the facility staff are not giving Resident #1 (R1) their medication as prescribed. It was reported R1 did not receive their prescribed antibiotic or psychiatric medication. R1’s Physician Report dated 12/13/21 indicated R1 was ambulatory with a diagnosis of diabetes and mental illness. The report reflected R1 was independent with bathing, dressing/grooming, feeding and toileting themselves. It also stated R1 required a diabetic diet, unable to store or manage their own medications. R1’s Resident Appraisal dated 10/17/22 indicated R1 required a diabetic diet and medication management but was able to handle their other activities of daily living. A review of the Medication Administrative Record (MAR) for September 2022 indicated an antibiotic was prescribed but not given, due to R1 not being present in the facility. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 6
Control Number 08-AS-20220919175153
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: 11/29/2022
NARRATIVE
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Further review of the MAR indicated R1 was not provided with a prescribed routine medication on 09/06/22, 09/07/22, 09/08/22 and 09/09/22, as the facility was waiting for a refill. Facilities are required to have the residents prescribed medications refilled timely so that no doses are missed. The facility failed to provide medications as prescribed. A review of the MARs for October 2022 indicated a different antibiotic was given than the one listed for September. The MARs for September and October 2022 were inaccurate, multiple medications were not given and/or documented incorrectly. The MARs reflected medications were not given but there was no reason provided on the back of the MAR as required and there were multiple medications that indicated a change in the order, but the change was not documented on the MARs. R1’s interviews confirmed not being provided with medications on multiple occasions. Administrator’s interview revealed not being aware R1 did not receive their medications as prescribed. The facility did not provide R1 with their medications as prescribed.

It was also alleged, the licensee did not maintain Resident #1’s (R1) room in a clean, safe, or sanitary condition. It was reported R1’s room had an odor, the window didn’t open, missing floor tiles, spider webs, and a towel rack barely held on by the screws. Outside source interviews revealed observing on 09/17/22 the window not opening, missing floor tiles, spider webs, and a towel rack barely held on by the screws. On 09/23/22, LPA observed R1’s room had a slight poor hygiene odor, missing floor tiles, and a towel rack barely held on by the screws. LPA also observed a small cane in the windowsill preventing the window from opening. Once the cane was removed, the window easily opened, no spider webs were observed. Outside source interviews revealed R1’s roommate moved out and left all their belongings behind in the bedroom. Staff interviews revealed R1’s roommate was Resident #2 (R2), who moved and no longer needed the items. Staff also stated R2 had poor hygiene, therefore, the odor could be coming from R2’s belongings left in the bedroom. Resident interviews revealed a preference of keeping the window locked by using a small cane as a locking device, not aware of the missing floor tiles, due to them being under the bed, and not observing spider webs.

On 11/08/22, Administrator and LPA toured R1’s room needing repair. Administrator was not aware of the missing tiles and the towel rack barely held on by the screws. Administrator’s stated R1’s room was currently under repair and R1 was permanently relocated to another room, prior to repairs. On 11/08/22, LPA observed the room under repair and observed new closet doors and a new heater. Administrator stated they will also replace/repair the missing tiles and towel rack and clean the room. LPA also observed R2’s belongings were removed. Continued on an LIC 9099C.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20220919175153
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: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2022
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Care Coordinator, Perla Barragan agreed to have all staff that administer medications attend vendor training and will schedule the training by POC due date and submit proof of training within 2 weeks.
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Based on interviews and record review the licensee did not assist with self-administered medications for (R1) 1 out of XXX residents in care. This posed an immediate health and safety risk to residents in care.
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A civil penalty was assessed for a repeat violation within a 12 month period.
Type B
12/27/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Care Coordinator, Perla Barragan stated the room has been cleaned and repairs have already been made.
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Based on observations and interviews the licensee did not provide a safe and sanitary environment for (R1) 1 out of XXX residents in care. This posed a potential health and safety risk to residents in care.
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A civil penalty was assessed for a repeat violation within a 12 month period.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/19/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20220919175153

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: 83DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Care Coordinator, Perla BarraganTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
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-Facility is not providing resident with a diabetic diet
-Licensee did not maintain a comfortable temperature for resident’s room
INVESTIGATION FINDINGS:
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5
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Care Coordinator, Perla Barragan.

During the investigation, the facility was briefly toured, records requested, and interviews with staff, residents and outside sources. It was alleged the facility is not providing Resident #1 (R1) with a diabetic diet. It was reported the facility is serving R1 Kool-Aid and ice cream. R1’s Physician Report dated 12/13/21 indicated R1 was ambulatory with a diagnosis of diabetes and mental illness. The report reflected R1 was independent with bathing, dressing/grooming, feeding and toileting themselves. It also stated R1 required a diabetic diet, unable to store or manage their own medications. R1’s Resident Appraisal dated 10/17/22 indicated R1 required a diabetic diet and medication management but was able to handle their other activities of daily living. LPA observed the facility’s kitchen and what was being served to diabetic residents. There was a red fruit punch that looked like Kool-Aid being served, but it was sugar free. The facility also had ice cream, cookies, and popsicles, which were all sugar free. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 6
Control Number 08-AS-20220919175153
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: 11/29/2022
NARRATIVE
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The facility uses a color coded chart to indicate specific diets. Staff interviews revealed there is a menu in place, however, they substitute certain items for residents that have special diets, such as diabetic. Staff stated they offer sugar free items such as ice cream so those residents that are not supposed to have certain items can still enjoy them. Administrator interview revealed they follow all special/modified diets and the kitchen staff are aware of all residents dietary restrictions. Administrator also stated they serve items that can be perceived as non-diabetic, such as ice cream and red fruit juice, yet they’re sugar free. Resident interviews revealed the kitchen staff is aware of dietary restrictions and comply. R1 admitted to eating and storing other food items in their room that are not of a diabetic diet. It was also alleged the licensee did not maintain a comfortable temperature for R1’s bedroom. It was reported R1’s bedroom was extremely hot, and the window didn’t open. On 09/23/22, LPA observed R1’s window and noted a small cane in the windowsill being used as a lock to prevent the window from being opened. LPA was able to remove the small cane and open the window. R1’s interview confirmed placing the small cane in the windowsill and prefers not to open the window, even in extreme heat. R1 had a fan in their room, which was being used by R1. Staff interviews revealed R1’s room was hot, however, they must respect R1’s rights of not wanting their window open. Staff stated they open the window when they are cleaning the room to let in fresh air, but must close it before they leave, as that is R1’s preference. It’s possible R1’s room was not maintained at a comfortable temperature, but it was due to R1’s choice and personal right to keep the room at the temperature the resident preferred.

Based on observations and interviews, 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 Care Coordinator, Perla Barragan whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20220919175153
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: 11/29/2022
NARRATIVE
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Based on LPA’s observations, record review, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Care Coordinator, Perla Barragan whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]. Civil penalties were assessed for both deficiencies as they were repeat violations within a 12 month period.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6