455002976-9-21-2023-59-AS-KHOS-CW2HTD-20230926062834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002976
Report Date: 09/07/2023
Date Signed: 09/21/2023 09:46:29 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
07/28/2023 and conducted by Evaluator Ivan Avila

COMPLAINT CONTROL NUMBER: 59-AS-20230728163040

FACILITY NAME:	GOLDEN OAKS SENIOR LIVING		FACILITY NUMBER:	455002976
ADMINISTRATOR:	WILLIAMS, KENNETH		FACILITY TYPE:	740
ADDRESS:	779 KERRYJEN CT.		TELEPHONE:	(530) 223-1538
CITY:	REDDING	STATE: CA	ZIP CODE:	96002
CAPACITY:	26	CENSUS:	DATE:	09/07/2023
		ANNOUNCED	TIME BEGAN:	08:32 AM
MET WITH:	Amber Greene		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

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Staff do not properly supervise resident, resulting in resident awoling from the facility.
Staff did not monitor resident for change in condition.

INVESTIGATION FINDINGS:

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This document has been amended on 09/21/2023 to reflect the appropriate deficiencies LPA Avila observed during the investigation that was previously recorded on 09/07/2023. LPA made an unannounced complaint investigation visit at this facility and met with Amber Greene.
On 04/26/2023 R1 exited the facility alone and was found later by staff. LPA interviewed staff and they stated R1 had walked out of the facility and was found some time after. On 04/28/2023 R1 exited the facility alone again and was found at the corner of the block. LPA interviewed Facility Manager (S1) and S1 stated that R1 was missing for approximately 20 to 30 minutes.
LPA interviewed staff and reviewed documents indicating that the Needs and Service plan for R1 was not updated to reflect R1s change of condition in leaving the facility alone and unassisted on 04/26/2023 and 04/28/2023.Based on LPAs interviews which were conducted and record reviews, the preponderance of
evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22 and or the California Health and Safety Code are being cited on the attached LIC 9099D and copy of report and appeal rights were provided to Amber Greene.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan Avila	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230728163040

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN OAKS SENIOR LIVING	FACILITY NUMBER: 455002976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/08/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 (a) Facility personnel shall at all times be sufficient in numbers...or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee had a training with all staff that was held by the local Ombudsman and went over the eloping procedures and reporting all incidents. Licensee placed call alarm matts in all the main exit doors in the facility to alert staff.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not provide adequate care and supervision by letting a dementia resident walk outside without supervision, which poses an immediate Health, Safety, Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 09/28/2023 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 (a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...shall document changes in the resident's physical, medical, mental, and social condition. The requirement is not met as evidence by:.	1 2 3 4 5 6 7	Licensee will start to implement an updated appraisal to a residents care plan once an incident occurs or a change of condition happens. Licensee will write up a plan to have a managers training to update a residents care plan and will email the plan to LPA.
	8 9 10 11 12 13 14	Bases on interviews and record review, the licensee did not update the residents appraisal after resident had a change in condition when leaving the facility alone and unassisted in two seperate incidents.	8 9 10 11 12 13 14

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: Lauren Crocker	TELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan Avila	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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