374602877-9-30-2022-08-AS-IESA-CJYUVX-20221007155553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602877
Report Date: 09/29/2022
Date Signed: 09/30/2022 10:20:23 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
11/30/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20201130081830

FACILITY NAME:	GOLDEN CARE FACILITY		FACILITY NUMBER:	374602877
ADMINISTRATOR:	ERIC CASTILLO		FACILITY TYPE:	740
ADDRESS:	2239 CRANDALL DRIVE		TELEPHONE:	(858) 560-6497
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92111
CAPACITY:	6	CENSUS: 4	DATE:	09/29/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Eric Castillo, Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision of resident resulted in multiple pressure injuries and hospitalization

INVESTIGATION FINDINGS:

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On 9/29/2022, at approximately 2:40 PM, Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced visit to the facility to conclude a complaint investigation. LPA was met at the entrance by Administrator, Eric Castillo. After identifying himself and displaying his department identification, LPA was allowed inside the facility. LPA explained the elements of the complaint to Administrator Castillo.

It was alleged that neglect/lack of care and supervision of a resident resulted in multiple pressure injuries and hospitalization. The Department’s investigation consisted of a review of facility and outside source records, observation and interviews with staff, responsible persons and outside sources.

Facility records showed that Resident 1 [LIC811 Confidential Names provided to Administrator Castillo to identify Resident 1 (R1), Staff 1 (S1) and Staff 2 (S2)] resided at Golden Care Facility since 10/08/2019. Per R1’s Physician’s Report, dated 10/4/2019, their primary diagnosis was Alzheimer’s, Dementia and Heart Failure. R1 was ambulatory and required assistance with bathing, dressing/grooming, feeding,

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 08-AS-20201130081830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE

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toileting and medication management.

It was reported that on 11/15/2020, S1 and S2 witnessed the development of pressure injuries on R1’s body. S1 and S2 treated the pressure injuries with over the counter (OTC) products. The wounds worsened. On 11/27/2020, S1 contacted R1’s responsible person and informed them about R1’s pressure injuries. S1 sent the responsible person photos of the wounds and suggested R1 be seen by a physician.

On 11/28/2020, R1’s responsible person transported R1 to the hospital where they were hospitalized for multiple pressure injuries. R1’s medical records reported a diagnosis of four pressure injuries, Stage 1, 3 and 4. Other unspecified wounds were noted including a scalp abrasion and lower left extremity bruising. Records identified two (2) Stage 1 pressure injuries, with superficial skin changes, located in an unspecified location and R1’s right hip. One (1) Stage 3 wound, located on R1’s left hip, was described as full thickness skin loss. One (1) Stage 4 pressure injury was noted on R1’s coccyx and described as “muscle tendon and/or bone” with malodorous discharge.

Investigation revealed that S1 and S2 failed to report the injuries to a physician or R1’s responsible person for twelve days. Interviews revealed that S1 and S2 admittedly did not notify R1’s responsible person or primary care physician (PCP) regarding R1’s change of condition until 11/27/2020. It should be noted that, generally speaking, licensees are required to report a change of condition to a physician and the resident’s responsible person. S1 and S2 stated that they attempted to treat R1’s open wounds with OTC products and without a physician’s consultation. A review of facility records revealed no evidence that neither S1 nor S2 are trained to provide medical care as part of their licensure. Facility records also noted that the facility does not have a hospice waiver.

During their interviews, S1 and S2 reported that they administered OTC products because they thought R1’s wounds would heal quickly, and they did not want to worry R1’s responsible person. Due to S1 and S2’s failure to arrange medical care for R1, the pressure injuries became infected.

R1 was discharged from the hospital on 12/07/2020 and transferred to a hospice care facility where they passed on 12/19/2020. Records reflect R1’s cause of death was listed as Alzheimer’s and Dementia.

Although R1’s cause of death is unrelated to the allegation, the Department’s investigation produced

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201130081830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE

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sufficient evidence to show that the facility’s neglect/lack of care and supervision resulted in multiple pressure injuries and hospitalization of R1. Based on the evidence obtained during this investigation, there is a preponderance of evidence to prove the allegation occurred. Therefore, the aforementioned allegation is Substantiated.

Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D. An immediate civil penalty of $500 was assessed during today's visit for the facility’s neglect/lack of care and supervision resulting in a resident’s multiple pressure injuries and hospitalization. At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

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 document.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20201130081830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 10/03/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care...(a) plan shall be developed...(1) licensee shall arrange...medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee will procure vendorized training for all facility staff regarding the identification and reporting of pressure injuries by the POC due date. Licensee will also submit a sign-in sheet to CCLD. On today’s date, the Department is issuing a $500.00 civil penalty under HSC 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee failed to notify the responsible person and physician and arrange for medical care in response to a change of R1’s condition, resulting in multiple pressure injuries and hospitalization. This posed an immediate health and safety risk to one (1) of three (3) residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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