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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 05/18/2022
Date Signed: 05/19/2022 02:31:13 PM

Document Has Been Signed on 05/19/2022 02:31 PM - It Cannot Be Edited

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:ROCIO GRANDAFACILITY TYPE:
740
ADDRESS:3223 DUKE STREETTELEPHONE:
(619) 222-1109
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY: 113CENSUS: 84DATE:
05/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Administrator, Rocio GrandaTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management – Deficiency visit. LPA met with Administrator, Rocio Granda and discussed the purpose of the visit was to issue deficiencies identified during a complaint investigation.

It was discovered during the investigation Resident #1’s (R1) records were not current or accurate to reflect R1’s needs. R1 was admitted to the facility on 04/27/21. R1’s Physician’s Report was dated 04/11/2019. Title 22 Regulations outlines prior to an admission, a medical assessment is required within the last year. R1’s Physician’s Report was not within one year of admittance to the facility. In addition, R1’s Physician’s Report indicated R1 was not allowed to leave the facility unassisted. However, the facility continues to allow R1 to leave unassisted. According to the administrator, R1 does not comply when instructed by the facility that they are not allowed to leave unassisted. The administrator has been made aware any resident that leaves the facility unassisted and the Physician’s Report indicated the resident is not allowed to leave unassisted is considered an elopement and elopement protocols must be followed.

Based on record review and interviews conducted deficiencies were observed and issued on the attached LIC 809D. 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]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/19/2022 02:31 PM - It Cannot Be Edited


Created By: Natasha Persaud On 05/18/2022 at 11:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
Section Cited
CCR
87464(f)(1)(c)

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Basic Services. Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Care and supervision" means the facility assumes responsibility for..ongoing assistance with activities of daily living without which the resident’s...welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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Administrator stated the facility will implement a new procedure that includes a list at the front desk to identify which residents are not allowed to leave unassisted. Administrator stated any resident that leaves that is not allowed to leave unassisted, the elopement plan will be followed. In addition, the
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This requirement is not met as evidenced by:
Based on record review and interviews, the licensee did not provide basic services for 1 out of 84 residents, by allowing R1 to leave the facility unassisted. This poses an immediately health and safety risk to residents in care.
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administrator stated she will schedule Elopement training by POC due date and provide proof of training along with the resident list within 2 weeks.
Type B
06/15/2022
Section Cited
CCR87458(a)

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Medical Assessment. Prior to a person's acceptance as a resident, the licensee shall obtain...a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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Administrator agreed to obtain a current physician’s report for R1. In addition, administrator stated the management team that handles admissions will attend outside vendor training regarding admissions. Administrator will provide proof of training once completed.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not ensure 1 out of 84 residents had a medical assessment within one year of admission. R1 was admitted in 2021 and their medical assessment was dated 2019. This poses a potential health and safety risk to residents.
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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 Tellez
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
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