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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397001613
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:10:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240729082312
FACILITY NAME:GOLDEN ACRES HOME AND CARE IIFACILITY NUMBER:
397001613
ADMINISTRATOR:MARIVIC TEANO-CHUAFACILITY TYPE:
735
ADDRESS:2002 E. HARDING WAYTELEPHONE:
(209) 943-5420
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:15CENSUS: 15DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Marivic Teano-ChuaTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff violated resident’s personal rights
INVESTIGATION FINDINGS:
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On 9/11/2024 at 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator Marivic Teano-Chua and explained the purpose of the visit. During this investigation, LPA conducted interviews with four residents and three staff. LPA also reviewed facility file documentation including facility house rules. Additionally, LPA conducted a facility observation on 8/07/2024.

Allegation: Staff violated resident’s personal rights. LPA conducted interviews, record review, and facility observation as noted above. Facility observation revealed facility has a cordless phone available to residents in care with same line shared for resident and staff use. Interviews and record review conducted revealed that although residents have access to a phone, facility house rules item #13 states: "Residents can use the home telephone upon approval by the staff from 8:00am to 9:00pm daily with a limit of three calls per day.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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 5
Control Number 27-AS-20240729082312
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER: 397001613
VISIT DATE: 09/11/2024
NARRATIVE
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All long distance calls must be approved and paid for with the rent in full monthly (Phone availability for an emergency is on a 24-hour basis)." Per regulatory resident rights, residents are to have access to telephone use and do not state limited number of phone calls or time frames of usage may be enforced by Licensee. House rule established indicates restrictions on access to phone usage.

As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided. LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240729082312
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER: 397001613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
CCR
85072(b)(9)
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Personal Rights. (b) The licensee shall insure that each client is accorded the following personal rights. (9) To have access to telephones in order to make and receive confidential calls…This requirement was not met as evidenced by:
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Licensee to update policy on resident telephone use to meet regulatory guidelines and to instruct staff on updated policy. Updated policy and proof of staff training to be sent to LPA by POC due date.
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Based on interviews, record reviews, and observation licensee does not ensure full usage and availability of phone service for residents in care. This poses a potential health, safety, and resident rights 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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240729082312

FACILITY NAME:GOLDEN ACRES HOME AND CARE IIFACILITY NUMBER:
397001613
ADMINISTRATOR:MARIVIC TEANO-CHUAFACILITY TYPE:
735
ADDRESS:2002 E. HARDING WAYTELEPHONE:
(209) 943-5420
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:15CENSUS: 15DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Marivic Teano-ChuaTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff mismanaged resident’s medication
Staff did not provide a comfortable temperature for residents
Staff did not meet resident's dietary needs
INVESTIGATION FINDINGS:
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On 9/11/2024 at 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Marivic Teano-Chua and explained the purpose of the visit. During this investigation, LPA conducted interviews with four residents and three staff. LPA also reviewed facility file documentation including facility house rules, facility menu, medication staff training documents. Additionally, LPA conducted a facility observation including meal service observation, and medication audit for various residents on 8/07/2024.

Allegation: Staff mismanaged resident’s medication. LPA conducted interviews and record reviews as noted above. LPA also conducted medication audit as noted above. Based on record reviews, it was revealed that medications on hand matched the accompanying physician orders. Additionally, it was revealed through record reviews and interviews that residents have been assisted with medication appropriately and accurately based on physicians’ orders.
{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240729082312
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN ACRES HOME AND CARE II
FACILITY NUMBER: 397001613
VISIT DATE: 09/11/2024
NARRATIVE
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Interviews conducted did not reveal any corroborated statements of medications being dispensed inaccurately. As a result, there is not a preponderance of evidence to conclude staff is mismanaging residents’ medication, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff did not provide a comfortable temperature for residents. LPA conducted interviews and facility observation as noted above. Based on observation, it was revealed that facility’s air conditioning unit was functioning properly, and facility was maintaining a temperature of 77*F, within regulatory required range. Interviews conducted did not reveal any corroborated statements of facility not maintaining comfortable temperature. Additional interview revealed facility’s air conditioning unit was discovered to require repair on 7-13-24 and was repaired on this same date. As a result, there is not a preponderance of evidence to conclude facility does not provide a consistent comfortable temperature for residents, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred.

Allegation: Staff did not meet dietary needs. LPA conducted facility observation as noted above. Additionally, LPA reviewed facility’s menu and conducted interviews as stated above. Based on record review, it was revealed that facility offers food which meets regulatory required nutritional guidelines at this time. Facility observation revealed food on hand and available is consistent with current established menu. Interviews conducted revealed facility is offering appropriate amounts of food and of good quality. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5