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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294287
Report Date: 11/25/2020
Date Signed: 11/25/2020 02:01:56 PM



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
09/24/2020 and conducted by Evaluator Grace Davis
COMPLAINT CONTROL NUMBER: 26-AS-20200924153946
FACILITY NAME:GOLDEN HILLS CARE HOMEFACILITY NUMBER:
435294287
ADMINISTRATOR:BASILIO, CARLOFACILITY TYPE:
740
ADDRESS:2845 WESTBRANCH DRIVETELEPHONE:
(408) 528-1325
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
11/25/2020
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Carlo BasilioTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not provide resident/responsible party contact information of CCLD and LTCO when requested.
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs) Grace Davis and Gladys Kuizon conducted a subsequent complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPAs met with Administrator (ADM) Carlo Basilio.

On 09/24/2020, the Department received a complaint with the above allegation. On 09/24/2020, LPA Gladys Kuizon interviewed the reporting party (RP) to obtain more information and on 10/01/2020, LPAs conducted an initial complaint investigation visit to interview facility administrator.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
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 5
Control Number 26-AS-20200924153946
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 HILLS CARE HOME
FACILITY NUMBER: 435294287
VISIT DATE: 11/25/2020
NARRATIVE
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On 10/01/2020 at 11:28AM, LPAs interviewed ADM. ADM stated that in September 2020, ADM had been in communication with resident (R1)’s responsible party (F1) regarding R1’s nail care. ADM stated that ADM and F1 had been having back and forth discussions regarding R1’s nail care because ADM is requesting R1 to be seen by R1’s physician for proper assessment on the type of staff that is qualified to groom R1’s nails due to R1’s hand being prone of infection. ADM stated that during this back and forth conversation, F1 requested the information of Community Care Licensing Division (CCLD) and Long Term Care Ombudsman (LTCO) by email. ADM stated that he did not provide CCLD and LTCO’s contact information because ADM and F1 resolved their disagreement and F1 was satisfied with the solution and did not ask for CCLD and LTCO’s information again.

Based on record reviewed, F1 requested ADM to provide contact information of CCLD and LTCO on two consecutive email messages dated 09/17/2020 and 09/18/2020. ADM responded to F1’s email on 09/21/2020 but did not provide CCLD and LTCO’s contact information.

On 09/24/2020, LPAs contacted LTCO, LTCO stated and confirmed that they have not been in contact with F1.

On 10/02/2020, 10/06/2020,10/14/2020, 10/16/2020 and 10/27/2020, LPAs attempted to reach F1 but was unable to obtain statements.

Based on LPAs’ observations, records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.


Exit interview was conducted with Administrator Carlo Basilio.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/24/2020 and conducted by Evaluator Grace Davis
COMPLAINT CONTROL NUMBER: 26-AS-20200924153946

FACILITY NAME:GOLDEN HILLS CARE HOMEFACILITY NUMBER:
435294287
ADMINISTRATOR:BASILIO, CARLOFACILITY TYPE:
740
ADDRESS:2845 WESTBRANCH DRIVETELEPHONE:
(408) 528-1325
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
11/25/2020
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Carlo BasilioTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
3
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9
Facility neglected resident's nail care,
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs) Grace Davis and Gladys Kuizon conducted a subsequent complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPAs met with Administrator (ADM) Carlo Basilio.

On 09/24/2020, the Department received a complaint with the above allegation. On 09/24/2020, LPA Gladys Kuizon interviewed the reporting party (RP) to obtain more information.

On 10/01/2020, LPAs conducted an initial complaint investigation tele-visit to interview facility administrator and staff. LPAs toured the facility and checked on residents. R1 nails were observed with contracture. Fingernails were observed short and clean.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
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 5
Control Number 26-AS-20200924153946
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 HILLS CARE HOME
FACILITY NUMBER: 435294287
VISIT DATE: 11/25/2020
NARRATIVE
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On 10/05/2020, LPAs conducted a subsequent unannounced tele-visit and observed all residents’ fingernails to be well-groomed, short in length, no visible dirt and no nail polish. Residents(R1-R3) were interviewed on 10/05/2020; R1 and R2 stated a manicurist groom their fingernails. R3 stated facility staff grooms R3's fingernails. 3 out of 3 facility staff stated they assist in bathing, dressing and grooming including nail care.

Based on record review, R1’s Admission Agreement includes basic care and supervision (dressing eating toileting, bathing, grooming and mobility tasks). Physician’s report dated 09/14/2020, noted that R1 has contractures on left hand making it prone to infection.

Email records dated 09/17/2020 to 09/22/2020, shows ADM was in constant discussion and communication with F1 about R1’s nail care. ADM requested F1 to seek medical advised for R1’s nail care. Based on the email dated 09/18/2020, F1 don’t want to hire a medical professional to maintain R1’s nails and wanted to do it himself. ADM drafted an agreement to documents who will be responsible for R1’s nail which F1 acknowledge the agreement and praised ADM for how it is written.

LPAs attempted to reach F1 on 10/02/2020, 10/06/2020,10/14/2020, 10/16/2020 and 10/27/2020 but was unable to obtain statements regarding the nail care.

Based on LPAs observations, interviews conducted and records reviewed, the Department found that the above allegation are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This report was discussed with administrator, Carlo Basilio. A copy was emailed to facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20200924153946
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 HILLS CARE HOME
FACILITY NUMBER: 435294287
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2020
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (a)(4)
To be informed by the licensee of the provisions of law regarding complaints and of procedures...including, but not limited to, the address and telephone number for the complaint receiving unit of the Department, and how to contact CCLD and the LTCO...This requirements was not met as evidence by:

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Facility to develop a written plan of action and submit to CCLD by POC due date.
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Based on email records reviewed and interview with the ADM and LCTO, ADM did not provide contact information of CCLD and LTCO. This posed a potential risk to the safety of resident.
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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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5