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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320024
Report Date: 07/02/2024
Date Signed: 07/03/2024 02:42:03 AM

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
06/24/2024 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20240624162458
FACILITY NAME:GOLDEN CARE LIVING IIIFACILITY NUMBER:
198320024
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1308 HICKORY AVETELEPHONE:
(310) 787-8369
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jeremy Nebres and Katherine EspinoTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff left residents in soiled diapers for an extended time
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, July 02, 2024, upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with staff member Jeremy Nebres. During the visit, Administrator Katerine Espino arrived to assist with the visit. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker conducted interviews with staff 1-3 (S1-S3) and residents 1-2 (R1-R2). Resident 3 (R3) was unable to communicate effectively due to a stroke, Resident 4 (R4) was non-verbal, and Resident 5 (R5) was not available for an interview as she was out with her family. LPA Bunker asked questions relevant to the nature of the complaint. S1-S3 agreed and stated it was true that the resident was left in soiled diapers for an extended time because one of the staff did not report to work and was a no-show. On that day, the facility was understaffed, with only one staff member on duty to provide care and supervision for five residents. Staff could only assist one resident at a time. See LIC9099-C page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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 4
Control Number 11-AS-20240624162458
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 III
FACILITY NUMBER: 198320024
VISIT DATE: 07/02/2024
NARRATIVE
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Continued LIC9099-C page 2

S1-S3 stated that meeting the residents' needs requires two staff members, but on Sunday, June 23, 2024, there was only one staff member available to manage the care of all five residents.

Staff Jeremy and LPA Bunker toured the entire facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit.

LPA Bunker requested and reviewed staff and residents' records. LPA Bunker requested pertinent documentation regarding the above allegation. (Identification and Emergency Information, Physician's Report, Medical Administration Record, Admission Agreement, Appraisal/Needs and Services Plan, Functional Capability Assessment, Personnel Report, Resident's Roster, Special Incident Report, Corrective Action Memo, and Ongoing In-Service Training)

Allegation #1: Staff left residents in soiled diapers for an extended time
S1-S3 stated that it is true the facility was not fully staffed on Sunday, June 23, 2024, with only one staff member on duty to care for five incontinent non-ambulatory residents. S1-S3 and R1-R2 stated that residents were left in soiled diapers for hours before staff could provide assistance.

Allegation #2 Staff are not meeting residents' needs
S1-S3 and R1-R2 stated on Sunday, June 23, 2024, staff did not meet the care needs of the residents for one day. S1-S3 and R1-R2 stated staff normally meet residents' care needs. R1-R2 stated they are generally happy with the care they receive, but on June 23, 2024, there were not enough staff on duty to assist residents as required. R1 mentioned that everything had been exceptional until the incident on that one day. S1-S3 and R1-R2 stated the staff addressed and resolved the issue.

Investigation revealed the following:
S1-S3 and R1-R2 stated that residents were left in soiled diapers for hours before staff could provide assistance. S1-S3 and R1-R2 stated on Sunday, June 23, 2024 staff did not meet the care needs of the residents for one day. S1-S3 and R1-R2 stated the staff addressed and resolved the issue.
See continued LIC9099-C page 3
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240624162458
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 III
FACILITY NUMBER: 198320024
VISIT DATE: 07/02/2024
NARRATIVE
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Continued LIC9099-C page 3

S1-S3 ensured that incontinent residents were kept clean and dry, the facility remained free of odors, and incontinent residents were checked regularly during known periods of incontinence. S1-S3 ensures sufficient and competent staff are available to provide the necessary services needed to meet residents' needs.

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D were provided to staff.

Appeal rights have been issued and discussed.

Exit interview conducted
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240624162458
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 III
FACILITY NUMBER: 198320024
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2024
Section Cited
CCR
87625(b)(2)(3)
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87625 (b) (2) (3) Managed Incontinence: The licensee shall be responsible for ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence
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The deficiency was corrected prior to today's visit. The staff ensured that incontinent residents were kept clean and dry, the facility remained free of odors, and incontinent residents were checked regularly during known periods of incontinence.
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odors from incontinence.
On Sunday, June 23, 2024 residents 1 and 2 were left in soiled diapers for an extended period because one of the staff did not report to work and was a no-show
The violation poses a potential health and safety risk to residents in care.
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Type B
07/02/2024
Section Cited
HSC
1569.2(c)
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1569.2 (c) Health and Safety Code:
The facility staff is responsible for providing care and supervision to meet residents’ needs, including assistance with daily living activities such as personal care, dressing, bathing, and managing incontinence of bowel and/or bladder.


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The deficiency was corrected prior to today's visit. The facility ensures sufficient and competent staff are available to provide the necessary services needed to meet residents' needs.
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The staff failed to meet the resident’s daily personal care needs.

The violation poses a potential 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4