374602369-9-17-2025-08-AS-LTEZ-DPXTUQ-20260102140243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 09/17/2025
Date Signed: 09/17/2025 03:52:14 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/10/2025 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20250910111033

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: 77	DATE:	09/17/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Administrator Rocio Granda		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff caused bruising to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Administrator Rocio Granda.

On 09/10/2025 it was alleged that staff caused bruising to Resident 1 (R1). The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, residents, outside sources, and records review. Staff interview revealed that R1 was frequently agitated and resisted care. Staff stated that during episodes of agitation R1 thrashed in their bed, hit their body on their bed rails, and has attempted to get out of their bed although they cannot walk, resulting in falling out of the bed. Staff additionally informed that fall mitigations were in place for R1 such as a low bed, fall mats, and half-rail padding to prevent R1 from injury. Staff informed that R1's hospice agency was contacted during each fall, and requests were made to evaluate R1's prescription due to their change in condition of increased agitation.
(Continued on LIC9099 p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

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-20250910111033

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOLDEN LIVING HEALTH MANAGEMENT, INC.	FACILITY NUMBER: 374602369
	VISIT DATE: 09/17/2025

NARRATIVE

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(Continued from LIC9099 p.1)

Staff informed that the hospice agency assessed R1 and a care conference was held regarding R1's change in condition, prescription update, and self-induced injuries that were occurring during the episodes of agitation.

During an unannounced facility visit LPA interviewed R1. LPA observed R1 to have bruises along their left arm and one bruise on their left leg during the facility visit. R1's explanations for these bruises were implausible due to R1 stating the left leg bruise was due to a pole on the wall that did not exist per LPA's observation, and that the arm bruises were due to an unknown person coming into R1's room years ago and hitting them. R1 resided in the facility's Memory Care unit and was not able to be qualified as a valid historian.

LPA attempted to contact three (3) outside sources for interview. LPA spoke with a hospice worker familiar with R1 who verified staff statements regarding R1 having frequent outbursts and attempting to climb out of their bed, resulting in falls. Additional requests for interviews from R1's hospice agency and an outside advocacy agency familiar with R1 were not returned.

Review of facility records during the timeframe of complaint showed staff documentation and communication to R1's hospice agency regarding bruising, frequent falls out of bed, agitation, and hallucinations by R1 that someone came into their room in the night and hit them. These records corroborated staff statements, outside source interview statements, and LPA direct observations during interview with R1.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Kitchen Supervisor Andres Barragan, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

LIC9099 (FAS) - (06/04)

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