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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602877
Report Date: 09/29/2022
Date Signed: 09/30/2022 10:23:17 AM


Document Has Been Signed on 09/30/2022 10:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GOLDEN CARE FACILITYFACILITY NUMBER:
374602877
ADMINISTRATOR:ERIC CASTILLOFACILITY TYPE:
740
ADDRESS:2239 CRANDALL DRIVETELEPHONE:
(858) 560-6497
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:6CENSUS: 4DATE:
09/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Eric Castillo, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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On 9/29/22, at about 3:35 PM, Licensing Program Analyst (LPA, Daniel Pena conducted an unannounced Case Management visit. LPA identified himself and discussed the purpose of the visit with Administrator Eric Castillo.

During today's visit, LPA toured the facility and briefly observed residents. The purpose of the visit was to issue deficiencies that were identified during a complaint investigation. While in care, Resident 1 (R1) [LIC811 Confidential Name list was provided to Administrator Castillo to identify R1] developed pressure injuries which required hospitalization.

It was reported that on 11/15/2020, facility staff witnessed the development of pressure injuries on R1’s body. Staff attempted to treat the pressure injuries with over the counter (OTC) products. The wounds worsened. On 11/27/2020, staff contacted R1’s responsible person and informed them about R1’s pressure injuries.

On 11/28/2020, R1’s responsible person transported R1 to the hospital where they were diagnosed and hospitalized for multiple pressure injuries. R1’s medical records reported a diagnosis of four pressure injuries, Stage 1, 3 and 4. Records noted the presence of two Stage 1 pressure injuries, with superficial skin changes, on an unspecified location and R1’s right hip. One Stage 3 wound, located on R1’s left hip, was described as full thickness skin loss and one Stage 4 pressure injury was noted on R1’s coccyx and described as “muscle tendon and/or bone” with malodorous discharge.

Investigation revealed that staff failed to report the injuries to a physician or R1’s responsible person for twelve days. Interviews revealed that staff admittedly did not notify R1’s responsible person or primary care physician (PCP) until 11/27/2020. It should be noted that, licensees are required to report a resident’s change of condition to a physician and the resident’s responsible person.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2022 10:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: GOLDEN CARE FACILITY
FACILITY NUMBER: 374602877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited

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Healing Wounds (a) the licensee shall...accept or retain a resident...who has a healing wound under the following circumstances: (3)...stage one or two pressure injury...diagnosed by a physician.(A)...resident shall receive care...from a physician. This requirement was not met as evidenced by:
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Based on interviews and record reviews, licensee failed to have multiple pressure injuries diagnosed and arrange for resident to receive care from a physician. This posed an immediate health and safety risk to one (1) of three (3) 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.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GOLDEN CARE FACILITY
FACILITY NUMBER: 374602877
VISIT DATE: 09/29/2022
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Based on interviews and record review, staff did not notify a medical professional or arrange for medical care for R1’s multiple pressure injuries. The preponderance of evidence standard has been met; therefore, the allegation is Substantiated. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC809-D.

An exit interview was conducted with Administrator Castillo, and a Plan of Correction was developed. A copy of this report, Licensee's Rights (LIC9058 01/16), LIC811 Confidential Names and copies of pertinent Title 22 Regulations, were provided to Administrator Castillo and their signature on this form confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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