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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200971
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:58:12 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230922163356
FACILITY NAME:GOLF VIEW HOMEFACILITY NUMBER:
079200971
ADMINISTRATOR:HIPOLITO, LORICAFACILITY TYPE:
740
ADDRESS:332 PEBBLE BEACH DR.TELEPHONE:
(925) 418-5613
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee Lorica HipolitoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not ensure resident was fed resulting in resident becoming severely malnourished
Staff did not monitor resident's water intake resulting in severe dehydration
Resident developed a pressure injury while in care
Resident developed a UTI while in care
Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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On 5/9/2024 at 10:15 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings on the allegations above. The LPA informed Licensee Lorica Hipolito of the reason for the visit.

The Department's investigation included, but was not limited to, interviews with staff, residents, and the Reporting Party (RP). The Department obtained and reviewed Resident’s (R1) hospital medical records and facility file. R1 was admitted to the facility on April 22, 2020.

Continues on LIC9099-C1 . . .
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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 6
Control Number 15-AS-20230922163356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971
VISIT DATE: 05/09/2024
NARRATIVE
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.... Continued from LIC9099

The complaint alleges that staff did not ensure the resident was fed, resulting in the resident becoming severely malnourished.
Medical records from R1’s hospitalization on 8/15/2023 revealed a diagnosis of severe protein-calorie malnutrition and weight loss. Those records indicated a weight loss of 34 percent over 16 months, from 188 pounds on 4/6/2022 to 123 pounds on 8/15/2023. When interviewed, the 3 staff members, Administrator (ADM) Lorica Hipolito, Caregiver S1, and Caregiver S2, stated that they had observed R1's loss of weight and change in condition during that period. They stated that R1 had an irregular sleeping pattern. R1 was awake for as many as 3 days in a row, followed by as many as 3 days of sleep. When awake, they reported that R1 had a good appetite. When R1 was asleep, R1 was not fed by the staff. Their neglect resulted in severe malnourishment and weight loss for R1.

The complaint alleges that staff did not monitor R1's water intake, resulting in severe dehydration.
When interviewed, all the 3 staff members, ADM, S1, and S2, stated that R1 had an irregular sleeping pattern. R1 was awake for as many as 3 days in a row, followed by as many as 3 days of sleep. All 3 staff stated that R1 was diabetic and would drink lots of water when awake. When R1 was asleep, R1 was not given any fluids by the staff. Their neglect resulted in R1 going for as many as 3 days in a row without drinking any fluids. R1’s hospital medical records revealed that on 8/15/2023 R1 was diagnosed with severe dehydration, which resulted in R1 experiencing an altered mental state due to a metabolic encephalopathy caused by R1’s dehydration superimposed on a Urinary Tract Infection (UTI).

The complaint alleges that R1 developed a pressure injury while in care.
R1’s hospital medical records revealed that R1 was diagnosed with an unstageable right ischial tuberosity pressure injury on 8/15/2023. R1 did not have any other records with the hospital documenting a history of pressure injuries for R1. Interviews with ADM and S1 revealed consistent statements of having knowledge about R1's pressure injury. ADM admitted that R1 had a pressure injury on R1’s buttock that was difficult to locate. ADM and S1 had conflicting statements about the stage of R1’s right ischial pressure injury. ADM denied seeing R1's pressure injury at the size and stage of that for which R1 was diagnosed on 8/15/2023 at the hospital.

Continues on LIC9099-C2 . . .
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20230922163356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971
VISIT DATE: 05/09/2024
NARRATIVE
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.... Continued from LIC9099-C1

The complaint alleges that R1 developed a UTI while in care.
R1’s hospital medical records revealed that on 8/15/2023, R1 was diagnosed with a Urinary Tract Infection (UTI). Medical records indicated that R1's UTI was a result of being malnourished and dehydrated. Interviews of ADM and S1 revealed inconsistent statements regarding R1's urine. ADM admitted observing R1 with discharge coming from R1’s penis about a week prior to R1 being transported to the hospital on 8/15/2023. ADM and S1 denied that R1 was in pain or needed assistance urinating. ADM and S1 denied that R1's urine had a foul odor or an unusual color.

The complaint alleges that staff did not seek medical attention for R1 in a timely manner.
R1’s hospital medical records revealed that on 8/15/2023, R1 was taken to the hospital by ambulance after the RP called 911. R1 was then diagnosed with dehydration, severe malnourishment, an unstageable right ischial pressure injury, and UTI. R1 was also diagnosed with experiencing an altered mental state due to metabolic encephalopathy caused by R1’s dehydration superimposed on R1’s UTI. Interviews with ADM and S1 revealed consistent statements of communicating R1’s change in condition with the RP and R1’s Primary Care Physician (PCP). ADM and S1 agreed that after communicating R1’s health with the RP and PCP, they did not take additional steps to address R1's declining health. ADM and S1 stated that R1's health was declining during 2023 and they failed to seek timely medical attention and that not seeking medical attention during that time resulted in the illnesses listed above.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D.

A $500.00 immediate civil penalty is assessed today. Licensee was informed that an additional civil penalty is still being determined based on Health & Safety Code 1569.49(f).

Exit interview conducted with Licensee and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20230922163356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
HSC
1569.269(a)(10)
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1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . .

This requirement is not met as evidenced by:
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A formal conference with CCLD will be scheduled at a later time.
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Based on reviews of R1’s hospital medical records and interviews of Administrator Lorica Hipolito, S1, and S2, it was revealed that R1 was not fed by the staff on a regular basis, resulting in a medical diagnosis of severe protein-calorie malnourishment and weight loss on 8/15/2023, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
05/10/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include … (1) Care and supervision as defined in … Health and Safety Code section 1569.2(c) … "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered…
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A formal conference with CCLD will be scheduled at a later time.
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This requirement is not met as evidenced by:
Staff members stated that R1 was not being given fluids for as many as 3 days in a row on a regular basis. From the 8/15/2023 hospital medical records, R1’s dehydration superimposed on a Urinary Tract Infection (UTI) resulted in metabolic encephalopathy causing R1 to experience an altered mental state. This poses an immediate health, safety or personal rights risk to persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20230922163356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
This requirement is not met as evidenced by:
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A formal conference with CCLD will be scheduled at a later time.
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Based on reviews of R1’s medical records from their hospitalization on 8/15/2023, it was revealed that R1 had an unstageable right ischial tuberosity pressure injury. R1 was retained in the facility despite having that unstageable right ischial tuberosity pressure injury, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
05/10/2024
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidenced by:
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A formal conference with CCLD will be scheduled at a later time.
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Based on reviews of R1’s hospital medical records, it was revealed that on 8/15/2023 R1 was diagnosed with a Urinary Tract Infection (UTI). Based on interviews of all staff members and a lack of facility documentation staff were not documenting changes to R1’s attention nor bringing those changes to the attention of the resident's physician and the resident's responsible person, if any, which poses an immediate health, safety or personal rights risk to persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20230922163356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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A formal conference with CCLD will be scheduled at a later time.
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Based on reviews of medical records from R1’s hospitalization on 8/15/2023, R1 was diagnosed with dehydration, severe malnourishment, an unstageable right ischial pressure injury, a Urinary Tract Infection (UTI), and experiencing an altered mental state due to metabolic encephalopathy caused by R1’s dehydration superimposed on R1’s UTI. It was R1’s responsible person, and not the facility staff, who called 911 to get R1 to the hospital, which poses an immediate health, safety or personal rights risk to persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6