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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200978
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:38:39 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
05/02/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220502145552
FACILITY NAME:GOLDEN NEST ASSISTED LIVINGFACILITY NUMBER:
079200978
ADMINISTRATOR:PRAMOD, KAVITHAFACILITY TYPE:
740
ADDRESS:2296 INDIAN SPRINGS DRTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Richard Romero, staff on duty TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision by staff resulted in resident sustaining a fracture
Staff did not seek timely medical attention for resident
Staff did not notify resident's authorized representative of incident
INVESTIGATION FINDINGS:
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On 08/24/2022 at 2:25PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with staff on duty S3, LPA called Administrator Kavitha Pramod and explained the reason for the visit. Administrator was not available during the visit and gave permission to LPA to read and have S3 sign the report.

During the course of the investigation, the Department conducted interviews with staff, residents, health providers, and complainant. R1’s medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed.

Allegation: Neglect/Lack of Care and Supervision by staff resulted in resident sustaining a fracture

…Continue to LIC9099C…
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
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 4
Control Number 15-AS-20220502145552
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: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
VISIT DATE: 08/24/2022
NARRATIVE
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On 4/30/2022 at about 10:00AM, staff (S6) found resident (R1) on the floor, S6 stated that she called another staff (S5) on duty to assist her on picking R1 up. S5 stated that prior to 4/30/2022 fall incident, he found R1 on the floor twice, but he never reported these incidents to Administrator. On 5/2/2022, S7 told S3 that R1 was complaining of pain during his shift (night shift), S3 stated that before he started his shift, he checked on R1 and found R1’s right leg swollen and bruised. S3 contacted the Administrator and informed her that R1 needs medical attention, Administrator advised S3 to call 911, but decided to wait for Assistant Administrator (S2). Based on records review, on 4/30/2022 at about 2:10PM, staff (S2) informed S1 about R1’s legs that it was painful when touched. S1 have knowledge of R1’s leg condition. Based on hospital records, R1 was diagnosed with hip fracture.

Records review stated R1 was non-ambulatory, needs and appraisal services indicated that R1 had limited mobility due to poor vision and needs transfer assist in getting in and out of bed.

Allegation: Staff did not seek timely medical attention for resident

Based on interview and records review, on 4/30/2022 at about 10:00AM resident (R1) was found on the floor. Based on interview S5 stated that prior to 4/30/2022 incident with R1, he found R1 on the floor twice, but was never reported to Administrator nor seek medical attention. Staff did not call 911 not until 5/2/2022 when S3 found bruises and swollen right leg on R1. Based on records review, on 4/30/2022 at about 2:10PM staff (S2) sent a picture of R1’s leg to S1 and informed her that it was painful when touched. On 5/1/2022 at around 1:31AM, staff (S7) informed S1 that R1 was complaining of right leg pain, on 5/1/2022 at around 7:18PM, staff (S2) sent a picture of R1’s leg to S1 showing R1’s bruises on her leg. R1 was not sent to hospital not until 5/2/2022.

Allegation: Staff did not notify resident's authorized representative of incident

Based on interview and records review, S5 stated that prior to 4/30/2022 incident, he found R1 on the floor twice, but he never reported these incidents to Administrator or to authorized representative, R1’s fall incidents was not reported to F1 not until R1 went to the hospital on 5/2/2022.

The preponderance of evidence has been met. Therefore, the allegations above are substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

A Non-Compliance Conference (NCC) will be scheduled at a later time.



Exit interview conducted. Appeal Rights and a copy of this report provided via email to Administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220502145552
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: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited
HSC
1569.269(a)(10)
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HSC Enumerated rights; severability.
To be free from neglect,..., intimidation, and verbal, mental, physical, or sexual abuse.

This This requirement is not met as evidenced by:
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By POC date, Administrator will conduct training with all staff of Sec. 1569.269 Enumerated Rights and submit proof of training and sign in sheet to CCL.
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Based on interviews & records reviews, Licensee did not comply with the regulation above, facility staff failed to assist R1, based on staff interview R1 fell more than once which resulted to hip fracture, which posed an immediate health & safety risk to resident in care.
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A Non-Compliance Conference (NCC) will be scheduled at a later time.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.
Type A
08/25/2022
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...
This This requirement is not met as evidenced by:
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By POC date, Administrator agrees to review regulation and conduct training with staff and submit a self-certification letter to CCL.
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Based on record review and interviews, Licensee did not comply with the regulation above, it was confirmed by multiple staff that staff did not immediately contact 911 when R1 was found on the floor on 4/30/2022, staff sent R1 at the hospital not until 5/2/2022, which poses an immediate health and safety risk to residents 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: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220502145552
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: GOLDEN NEST ASSISTED LIVING
FACILITY NUMBER: 079200978
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
87211(a)(1)
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REPORTING REQUIREMENTS
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident....
This This requirement is not met as evidenced by:
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Administrator agrees to review regulation and obtain training with a vendor covering topic. By POC date, Administrator will submit a registration confirmation and self-certification letter on understanding of regulation to CCLD.
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Based on interview and records review Licensee did not comply with the regulation above, staff failed to report to responsible party regarding R1’s fall incidents, including two fall incidents prior to 4/30/2022, which posed a potential health & safety risk to resident 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: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4