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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602369
Report Date: 01/16/2026
Date Signed: 01/16/2026 02:16:26 PM

Substantiated


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
07/29/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20220729155959
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: 73DATE:
01/16/2026
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Administrator, Rocio GrandaTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Neglect resulting in serious bodily injury
Staff did not assist resident with showering needs
Licensee did not address residents change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA met with Administrator, Rocio Granda and discussed the above mentioned allegations.
During the investigation, the Department reviewed records, conducted interviews with staff, residents, and outside sources, and briefly toured the facility. It was reported that R1 was neglected resulting in serious bodily injury. R1 arrived at the hospital on 7/26/2022 with maggots surrounding a left leg wound with a foot infection. It was also reported that R1 was not receiving shower assistance. R1 confirmed they could not recall the last time they received a shower at the facility. Lastly, it was reported the licensee did not address R1’s change in condition. The administrator stated they were not aware of the wound or change in condition and the facility does not offer wound care. However, the Wellness Director’s (WD) interview confirmed they had knowledge that R1 had an infection on their left foot, which started with R1’s toe and got worse. The WD explained that R1’s physician came to the facility every Tuesday to check on R1. WD also stated the caregivers were not qualified to treat or care for the wound; they could only wrap the wound. Continued on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
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 7
Control Number 08-AS-20220729155959
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: 01/16/2026
NARRATIVE
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R1’s Physician’s Report dated 11/29/2021 indicated R1’s had motor impairment/paralysis, and was unable to bathe, dress/groom, and transfer to and from bed. R1’s Resident Appraisal dated 09/27/2021 indicated R1’s overall health appears fair and required a dialysis diet. It also showed that R1 required assistance with the following: transferring in and out of bed; toileting; dressing; bathing; hair care; personal hygiene; help with moving about the facility; medication management; and help in participating in activities. Also, R1 was receiving dialysis three times a week. The administrator’s interview confirmed that R1 was receiving full service for activities of daily living. The facility’s Body Check form for R1 dated 09/27/2021 indicated R1 had scars on their left arm from dialysis and a small ulcer on left side ankle/dryness in both feet and toes. R1 was supposed to receive a shower once per week. However, staff were not providing a shower to R1 as the wound had been observed by staff. R1’s Admission Agreement (AA) dated 09/27/21 indicated R1 was a Level 4. Level 4 identified on the AA which reflected the following services: escort AM/PM; bathing; dressing; grooming; and 2hr checks.

R1’s medical records indicated R1 was evaluated by their Primary Care Physician (PCP) on 7/15/2022. At that time R1 had a 1x1.5cm ulcer at the base of their left fourth toe with discharge present. One-week history of blister of left foot with progressed pain, at a high level, not relieved by pain medication. Skilled nursing was ordered for wound care. R1 skipped dialysis twice in one week due to left foot pain. R1 had shaking chills and had not been receiving would care at their facility. There was a vast increase in size of the wound of left foot from 5cm ulcer at base of left toes, dorsal surface, induration/discharge/foul odor/soiled dressing present. Concerns of sepsis with high risk for amputation, PCP called 911 and transferred care to Emergency Medical Services.

A further review of R1’s medical records indicated the chief complaint for the hospitalization on 07/25/2022 was for leg pain with bacterial skin infection on left foot. The wound on R1’s left foot was classified as Class IV wound- dirty or infected is a classification for surgical wounds that are significantly contaminated. The report also stated the large, infected wound on the left foot extended from the plantar to the dorsal aspect. In addition, the report indicated that the foot is swollen, there is a foul-smelling oozing open wound over the MTP joints from T2-T5, there are some maggots seen on the lateral aspect of the wound. A left below-knee amputation surgery was performed due to nonhealing infected left foot wound, peripheral vascular disease.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20220729155959
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: 01/16/2026
NARRATIVE
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Staff interviews confirmed R1 had a change in condition. Staff stated when R1 first moved in, they were “half-independent”. R1 used both wheelchair and walker at the facility, was active and able to propel themselves in their wheelchair. R1 was also able to use the bathroom independently. Once R1 became less independent, diaper changes were provided. However, the facility did not conduct the required reappraisal when R1 had a change in condition and/or obtained a current Physician’s Report. The Care Coordinator’s (CC) interview confirmed there was a change in condition when the CC went to a nursing home to assess R1 after the leg amputation and bring R1 back to the facility. The CC stated R1 needed help with transferring from bed to wheelchair and became a two-caregiver assist. The reappraisal was not conducted for R1. Resident interviews confirmed they observed maggots on R1’s leg due to a leg infection, along with a bad odor, and reported it to staff.

The administrator confirmed R1 was not receiving home health services prior to 7/26/2022. The administrator explained R1 was being treated for the wound by their PCP, and it was up to the PCP to determine and order home health for wound care. Administrator further stated that if home health was pending/resident waiting, then they can get involved and assist. Also, if a resident’s situation got worse fast, staff would send the resident out to the hospital for treatment. PCP’s interview stated they attempted to get R1 skilled nursing services, as it’s the PCP’s responsibility. However, R1’s medical insurance was very limited and difficult, it never went through. PCP also suggested many times to R1, to transfer to a skilled nursing facility where their needs would be better met. However, R1 declined to move and stated they liked it at the facility. In addition, the PCP said they asked R1 many times to send R1 out to the hospital as they could not get home health or other care needed, but R1 declined offers. PCP explained they did not provide any instructions to staff once the infection was identified due to staff not having any nurses or staff that were trained or qualified to change and care for the wound. The facility staff failed to provide adequate care for R1 which resulted in a serious medical condition.

Based on LPA’s observations and interviews which were conducted and record review, 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 03/22) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1] A civil penalty in the amount of $500 was assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. Determination of Civil Penalties under Health and Safety Code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 08-AS-20220729155959
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2026
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights ... (a)…residents… shall have... the following personal rights: (4) To care, supervision, and services that meet their... needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs.
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The administrator agreed to attend training along with staff regarding topics of care and supervision.

A $500 immediate civil penalty was assessed and will be ongoing until corrected.
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This requirement was not met as evidenced by:
Based on interviews and records review the licensee did not provide care and supervision to 1 out of 84 [R1] residents, which posed an immediate health, safety, and personal rights risk residents in care.
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Type A
01/17/2026
Section Cited
CCR
87466
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Observation of the Resident. The licensee shall ensure that residents...observed for changes in physical, mental...assistance is provided when such observation reveals unmet needs. When changes...shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any
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The administrator agreed to schedule an in-service training on observation of the resident and send proof of scheduling by POC due date. The administrator agreed to send proof of training within 2 weeks.
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This requirement was not met as evidenced by:
Based on interviews and records, the licensee did not observe a change in condition for 1 out of 84 [R1[ residents, which posed an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20220729155959
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2026
Section Cited
CCR
87464(f)(4)
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Basic Services. Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal... and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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The administrator agreed to attend in-service training on Basic Services and submit proof of training by POC due date.
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This requirement was not met as evidenced by: Based on interviews and records, the licensee did not ensure 1 out of 84 [R1] residents received assistance with bathing as documented, which posed a potential health, safety, and personal rights risk residents in care.
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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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
07/29/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20220729155959

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: 73DATE:
01/16/2026
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Administrator, Rocio GrandaTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff did not provide medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA met with Administrator, Rocio Granda and discussed the above mentioned allegation.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that staff did not provide medication as prescribed. It was reported staff did not distribute Resident #1’s (R1) insulin injections. R1 was a diabetic and prescribed morning and evening insulin. R1’s medications were managed by the facility but R1 administered their own insulin injections. R1’s Medication Administration Records (MAR) dated 06/23/22-07/22/22, reflected Lantus Solostar injection AM and PM, but the MARs were not signed as administered, it was blank. The Wellness Director stated the medication technicians did not document correctly when R1 administered their own insulin. The Wellness Director also stated there were days when R1 would refuse their insulin. The department was unable to determine if R1 was provided with their prescribed insulin. Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20220729155959
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: 01/16/2026
NARRATIVE
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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 Administrator, Rocio Granda whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7