435294261-10-21-2020-26-AS-KHOS-BUTPWN-20201028114057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294261
Report Date: 10/21/2020
Date Signed: 10/21/2020 10:45:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200903153822

FACILITY NAME:	GOLDEN HERITAGE SENIOR LIVING		FACILITY NUMBER:	435294261
ADMINISTRATOR:	MAR, DANNY		FACILITY TYPE:	740
ADDRESS:	1275 N. FOURTH STREET		TELEPHONE:	(408) 392-0752
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	68	CENSUS: 0	DATE:	10/21/2020
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Danny Mar		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility has flea infestation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit over telephone and spoke with Administrator Danny Mar. The visit was conducted over telephone due to the ongoing COVID-19 Shelter-in-Place order.

On 09/10/2020, LPAs Marrufo and Ng conducted a telephone visit at the facility and interviewed staff S1-S5 and residents R1-R5. Two out of five staff reported to have observed flea bites on themselves but did not observe fleas at the facility. Three out of five staff stated to have not experienced flea bites and did not observed fleas at the facility. None of the interviewed residents stated to have observed flea bites on themselves or to have observed fleas at the facility.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

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 2

Control Number 26-AS-20200903153822

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: GOLDEN HERITAGE SENIOR LIVING	FACILITY NUMBER: 435294261
	VISIT DATE: 10/21/2020

NARRATIVE

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. LPA also obtained a copy of pest control service contracts from the facility for months of 08/2020, 07/2020, and 06/2020. The contracts state that residual liquid treatment was applied to the exterior of the facility. LPA also obtained a photograph of the container of Ortho Home Defense Max that facility staff reported during interview to use on the interior of the facility. During interview, Administrator Danny Mar stated that although there were no issues with fleas recently at the facility, there had been observations of stray cats in the facility parking lot and he had staff clear the parking lot of the stray cats. He stated that about two weeks prior, fewer than 10 staff had reported that they had itchiness or bites, but no resident reported itchiness or bites.

On 09/11/2020, LPA Marrufo conducted a telephone interview with a contact person at the pest control company that the facility had contracted. During interview, the contact person stated that due to concerns about the COVID-19 pandemic, the facility did not permit pest control staff to enter the facility building since June. The pest control contact person stated the company sprays outside of the facility for roaches, fleas and all other bugs.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. Although staff did report bites on their skin, there is not a preponderance of evidence to prove that the bites were from fleas or that the bites came from the facility. Neither interviewed staff nor residents stated to have observed fleas in the facility.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Administrator Danny Mar. A copy of the report will be sent to Mr. Mar so that it may be signed and returned to CCL.

Page 2 of 2.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2