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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607206
Report Date: 12/13/2023
Date Signed: 01/18/2024 01:51:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20231206154114
FACILITY NAME:GOLDEN CARE LIVING, INC.FACILITY NUMBER:
197607206
ADMINISTRATOR:ANGELIQUE S. GRADNEYFACILITY TYPE:
740
ADDRESS:2052 REDONDELA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:ADMINISTRATOR ANGELIQUE GRADNEYTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not keep a resident's room free from odor
Staff did not properly maintain a resident's bed while in care
Staff did not ensure a resident showered while in care
Staff did not properly report an incident involving a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT SUPERSEDES THE REPORT DATED 12/13/2023 FOR CLARIFY THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS HAVE NOT CHANGED: SUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Golden Care Living Facility on 12/13/2023 and was greeted by Administrator Angelique Gradney (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
During this investigation, LPA Calderon interviewed A1, S1-S2, R1-R4. These interviews were conducted on 12/13/2023. On 12/13/2023 LPA Calderon obtained and reviewed copies of the following: Eviction letter (date 10/11/2018 and 3/12/2019), Physician Report (dated 01/18/2018), Capability assessment (date 2/13/2017). Needs and Service plan (date 2/3/2022) Toured the facility (date 12/13/2023).
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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 6
Control Number 11-AS-20231206154114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING, INC.
FACILITY NUMBER: 197607206
VISIT DATE: 12/13/2023
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
Regarding Allegation #1: Staff did not keep a resident’s room free from odor.

This complaint alleged staff did not keep R1 room free from odor. LPA Calderon conducted an interview with A1. A1 states that R1 refuses to allow staff to clean R1 room or allow pest control to spray for fruit flies. A1 states that staff cleans R1 room and attempts to control the odor in R1 room. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 refuses to allow staff to clean R1 room. 2 out of 2 staff state that when R1 is not in R1 room staff cleans R1 room. 2 out of 2 staff state that staff attempts to control the room odor but due to R1 urine it is hard to control odor in R1 room. LPA Calderon conducted an interview with R1-R4. 4 out of 4 residents were not capable of answering any questions due to health issues. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted R1 room had an odor of urine. LPA Calderon noted R1 in soiled pants while inside R1 room.

Regarding Allegation #2: Staff did not properly maintain a resident’s bed while in care.

This complaint alleged staff did not maintain bed for R1. LPA Calderon conducted an interview with A1. A1 states that R1 does not allow staff to clean his bed or change R1 mattress sheets. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 does not allow staff to clean R1 bed. 2 out of 2 staff state that when R1 is not inside R1 room staff changes R1 bed sheets. 2 out of 2 staff state that R1 does not allow staff to put plastic sheet on the bed to protect the mattress from R1 urine. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted that R1 bed had a urine spot. Appears R1 had urinated in the bed. LPA Calderon noted R1 bed mattress was soiled and ripped up and needs to be replaced. LPA Calderon noted that staff wanted to put clean sheets on R1 wet bed without addressing the urine spot in R1 mattress.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20231206154114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING, INC.
FACILITY NUMBER: 197607206
VISIT DATE: 12/13/2023
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
Regarding Allegation #3: Staff did not ensure a resident showered while in care.

This complaint alleged staff did not make sure R1 showered or clean self.

LPA Calderon conducted an interview with A1. A1 states that R1 refuses to take a shower or have staff help R1 to take a shower. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R1 refuses to take a shower and staff cannot force R1 to take a bath or shower. 2 out of 2 staff state that R1 can take a shower by R1 self. LPA Calderon conducted an interview with R1 who was sitting in a wheelchair. R1 appeared confused and under the influence of alcohol. LPA Calderon noted that R1 had a vodka bottle on the side of R1 wheelchair and was taking drinks out of the bottle. LPA Calderon asked R1 to stop drinking prior to the interview. R1 states that R1 has not taken a shower for 3 days. 3 out of 3 residents were not able to give an interview regarding showering due to health issues. On 12/13/2023 LPA Calderon toured the facility with A1. LPA Calderon noted that R1 appeared to not be clean and was wearing soiled pants. LPA Calderon noted R2-R4 appeared to be clean and wearing clean clothes. LPA Calderon did not review any shower logs for R1 or any other resident. Reviewed capability assessment (date 2/13/2017) for R1, baths or showers without help, uses toilet by self. Reviewed physician report (date 1/18/2018) for R1, report notes health issues. Reviewed resident appraisal (date 2/3/2022) for R1, noted health issues for R1. Reviewed needs and service plan (dated 2/3/2022) for R1, noted health issues.

Regarding Allegation #4: Staff did report an incident involving a resident.

This complaint alleged staff did not keep incident reports for R1. LPA Calderon conducted an interview with A1. A1 states that R1 has lived in the facility for the past 6 years. A1 states that no incident reports have been written up on R1 actions such as not showering and refusing to allow staff to clean R1 room. A1 states that S1 kept handwritten notes from 07/01/2023 to 12/01/2023 regarding R1 not allowing staff to clean R1 room, R1 refusal to take a bath or shower or clean R1 bed. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that they did not write any formal incident reports regarding R1 room, refusal to take a shower, change R1 bed or sheets. 2 out of 2 staff state that S1 kept some handwritten notes for R1 from 7/1/2023 to 12/01/2023 regarding R1 refusal to take a shower, clean R1 bed or room or control the odor in R1 room. LPA Calderon reviewed R1 facility notes and LPA Calderon could not find any incident reports for R1 regarding room odor, bed status, or showering.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20231206154114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING, INC.
FACILITY NUMBER: 197607206
VISIT DATE: 12/13/2023
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
Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegations of “staff did not keep a residents room free from odor”, “staff did not properly maintains a residents bed while in care”, “staff did not ensure a resident showered while in care”, “staff did not properly report an incident involving a resident “is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citation issued (ref LIC9099D).

A face-to-face meeting was conducted with Administrator Angelique Gradney and a hard copy was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20231206154114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING, INC.
FACILITY NUMBER: 197607206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights...(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee will confirm staff cleans residents room and controls the odor for room. Licensee will confirm resident room free of odor by 12/22/2023
8
9
10
11
12
13
14
Licensee did not ensure that resident room was clean and free of odor.This poses an immediate health and safety risk to all residents in care.
8
9
10
11
12
13
14
Type B
12/22/2023
Section Cited
CCR
80072(e)(3)
1
2
3
4
5
6
7
80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights...(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee will make sure that resident mattress is replaced and a plastic sheet is put on bed to control resident urine.
8
9
10
11
12
13
14
LIcensee did not change the bed and sheets This poses an immediate health and safety risk to all residents in care. This requirement was not met as evidence by:
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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20231206154114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING, INC.
FACILITY NUMBER: 197607206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
80069.2(a)(1)
1
2
3
4
5
6
7
80069.2 Functional Capabilites Assessment (a) In order to determine whether the facility's program meets a client's services needs,(A) Does not bathe or shower self. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee will ensure resident take a show and keep shower log notes and show LPA proof of shower logs bu POC date
8
9
10
11
12
13
14
LIcensee did not ensure resident took a shower. This poses an immediate health and safety risk to all residents in care.
8
9
10
11
12
13
14
Type B
12/22/2023
Section Cited
CCR
80061(b)(1)(e)
1
2
3
4
5
6
7
80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, (1) Events reported shall include the following:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee shall keep detailed records and incident repots for resodent care.
8
9
10
11
12
13
14
Licensee did not generate incident reports for resident refusal to shower, clean resident room or change the bed sheets. This poses an immediate health and safety risk to all
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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6