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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200971
Report Date: 03/28/2025
Date Signed: 03/28/2025 12:37:00 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, 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
02/26/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240226151116
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: 6DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lorica Hipolito, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Neglect resulting in resident developing pressure injury and hospitalization
INVESTIGATION FINDINGS:
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On 03/28/2025 at 10:15 a.m., Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver findings on the allegation above. The LPA informed Administrator, Lorica Hipolito of the reason for the visit.

Allegation: Neglect resulting to resident developing pressure injury and hospitalization – Substantiated

The Department's investigation included, but was not limited to, interviews with staff, home health nurse, home health director, and the Witnesses (W). The Department obtained and reviewed Resident’s (R1) hospital medical records and facility file.

Continues on LIC9099-C1 . . .
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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 15-AS-20240226151116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971
VISIT DATE: 03/28/2025
NARRATIVE
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R1’s after summary visit indicated that R1 wound was at a stage two but it was manageable. According to S1 observation R1 wound was on the merge of develop to a stage three, but it was manageable with preventative care. W3 advise the care staff to make sure to rotate the resident every two hours, and make sure to have some time for the resident to be air out. W3 came three time within a week, and the wound got worse. The staff keep on telling the family that the resident was doing better and getting better, but as a wound nurse the condition was getting worse. The family finally agree to send R1 to the hospital. During the interview process when care staff was asked why they didn’t call 911 if R1 condition was getting worsen. Care staff indicated that R1 family member didn’t agree for us to call 911 emergency, but contact the non-emergency. W2 and W3 observed that R1 was not being clean and observed R1 wound got worsen even though care staff claimed that had follow the advised that was given. W3 observed that R1 was being neglected and was left in solid diaper, and had reminded them many times and gave them multiples instruction, and as well as paper instruction. W2 observed that all the paper instruction was gone. From my experience as an RN if a resident was being taken care of as instructed the wound would not get worse and develop to a stage four. W1 stated “Yes, I believed that the facility takes go care of my mom, but in term of rotating my mom they were not doing as much as they were supposed to do. At the end we can see that my mom condition got worse. The facility never suggested that my mom would got worsen, until I was notified by the ACI nurse”.

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.

Exit interview conducted with Administrator Lorica Hipolito a copy of this report and appeal right was provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240226151116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLF VIEW HOME
FACILITY NUMBER: 079200971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2025
Section Cited
HSC
1569.269(a)(6)
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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:
(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidenced by:
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Administrator agrees to review the citied section and self-certified the understanding the citied session, also conduct an in-service training on wound care. Administrator will start to record keeping of each residents on diaper changing, health care note, and time and date of personal hygiene and submit to CCLD by POC date.
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Based on records reviewed and interviewed shows R1 wound was manageable at a stage 2 but develop to a stage 4 because S1 did not follow the care instruction by not rotating R1 every two hours, left R1 in solid diaper, also S1 did not let R1 wound air out prior to changing R1.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
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