<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804024
Report Date: 03/24/2023
Date Signed: 03/24/2023 02:57:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230125101412
FACILITY NAME:GOLDEN VIEW CARE HOMEFACILITY NUMBER:
486804024
ADMINISTRATOR:PRINCE, OLUWABUNMI WURAOLAFACILITY TYPE:
740
ADDRESS:362 MEADOWS DRIVETELEPHONE:
(707) 644-2399
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 0DATE:
03/24/2023
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Oluwabunmi Prince, TIME COMPLETED:
03:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of care/supervision resulting in resident going AWOL
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/24/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint findings to the facility and was greeted by Licensee, Oluwabunmi Prince and Administrator, Tedra Godfrey. During the course of the investigation, LPA obtained facility and outside Vallejo Police Department documents for review and made observations.

Complaint alleges facility lack of care/supervision resulting in resident going AWOL. Based on a review of Vallejo Police Department (VPD) records LPA found that on 5/7/2022, VPD received call for a missing person, resident (R1) from facility Licensee, Oluwabunmi Prince. Baed on medical records, it is determined that R1 is unable to leave the facility unassisted and was found to be out in the community alone without staff knowledge.
Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
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 3
Control Number 21-AS-20230125101412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GOLDEN VIEW CARE HOME
FACILITY NUMBER: 486804024
VISIT DATE: 03/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In addition, Vallejo Police Department body cam footage shows alleged victim in AWOL incident. Upon interviews and photo documentation from outside party (I1), LPA confirmed that the resident in the body cam footage is the same resident/victim (R1) in the AWOL incident under investigation.

Allegation, lack of care/supervision resulting in resident going AWOL is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230125101412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN VIEW CARE HOME
FACILITY NUMBER: 486804024
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2023
Section Cited
CCR
87705(b)(2)
1
2
3
4
5
6
7
87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on a review
1
2
3
4
5
6
7
Licensee/Administrator will be reviewing regulation 87705 Care of Persons with Dementia with staff and Licensee. In addtion facility will person leaves the facility to ensure that
8
9
10
11
12
13
14
of Vallejo Police Department records it was found that residnet (R1) had been reported by Licensee to be missing from facility care. Medical documents indicate diagnosis of dementia.
8
9
10
11
12
13
14
exits are properly alarmed preventing possible AWOL. LIC9098 Proo of Corrections form confirming review of regulation to be submitted by POC due date 3/27/2023.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3