198320024-10-30-2024-11-AS-UCOL-DB2SZQ-20241115131928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320024
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:56:38 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
10/16/2024 and conducted by Evaluator Socorro Leandro

COMPLAINT CONTROL NUMBER: 11-AS-20241016091424

FACILITY NAME:	GOLDEN CARE LIVING III		FACILITY NUMBER:	198320024
ADMINISTRATOR:	GRADNEY, ANGELIQUE		FACILITY TYPE:	740
ADDRESS:	1308 HICKORY AVE		TELEPHONE:	(310) 787-8369
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Caregiver - Daniel Aliony		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not check on resident every 2 hours for incontinence care
Staff did not answer residents calls for assistance

INVESTIGATION FINDINGS:

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On 10/30/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced subsequent complaint visit at this facility. CCLD staff was greeted by Caregiver Daniel Aliony. CCLD staff explained the purpose of this visit.

The investigation consisted of the following:
On 10/17/2024, The department interviewed 4 out 6 residents and 3 staff. The department gathered facility timesheets for the month of October 2024 and resident records.
On 10/30/2024, The department interviewed 1 out 6 residents. The department attempted to interview 1 out 6 residents but resident was sleeping. The department conducted a tour of the facility.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241016091424

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: 10/30/2024

NARRATIVE

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The investigation revealed the following:

Regarding the allegation “Staff did not check on resident every 2 hours for incontinence care”, it is being alleged that Resident 1 (R1) was not assisted with incontinence care on 10/15/2024 from 2:00 AM to 6:00 AM. Interviews conducted revealed the following: 5 out 5 residents indicated that staff does not check on them or assist them from 2:00 AM to 6:00 AM. 4 out 5 residents indicated that there is no night staff. R1 indicated that she was not assisted with incontinence care at night. 3 out of 3 staff indicated that they do not work from 2:00 AM to 6:00 AM. 3 out of 3 staff indicated that their “Daily Time Sheet” is correct. Records reviewed of Daily Time Sheets revealed the following: “Daily Time Sheet Caregiver 1” “Covered Dated Oct. 1-15, 2024” demonstrates that Caregiver 1 works from 7:00 AM to 7:00 PM; according to the time sheet Caregiver 1 worked on 10/15/2024 from 7:00 AM to 7:00 PM. “Daily Time Sheet Caregiver 2” “Covered Date” Oct. “1-15, 2024” demonstrates that Caregiver 2 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 2 worked on 10/15/2024 from 8:00 AM to 8:00 PM. “Daily Time Sheet” for Caregiver 3 “Covered Date Oct. 1-15, 2024” demonstrates that Caregiver 3 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 3 did not work on 10/15/2024. Resident 1’s records revealed the following: “Physician’s Report for Residential Care Facilities for the Elderly” indicated that R1 needs incontinence assistance; “Resident Appraisal for Residential Care Facilities for the Elderly” states “Services Needed” with incontinence care; “Appraisal/Needs And Services Plan” states “Physical/Health: Incontinent, Provide Assistance on their Toileting Needs, Time Frame: Length of stay, Method of Evaluating Progress: Daily Observation and Monitoring”; “Admission Agreements for Residential Care Facilities for the Elderly” states that R1 will be receiving assistance with “toileting” and “other personal care needs.” Regarding the allegation “Staff did not check on resident every 2 hours for incontinence care”, the preponderance of the evidence standard has been met therefore the allegation is substantiated.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241016091424

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: 10/30/2024

NARRATIVE

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Regarding the allegation “Staff did not answer residents calls for assistance”, it is being alleged that R1 called for help on 10/15/2024 from 2:00 AM to 6:00 AM and staff did not assist R1 with R1's incontinence care needs. Interviews conducted revealed the following: 5 out 5 residents indicated that staff does not check on them or assist them from 2:00 AM to 6:00 AM. 4 out 5 residents indicated that there is no night staff. R1 indicated that she called for assistance at night time and staff did not assist them. 3 out of 3 staff indicated that they do not work from 2:00 AM to 6:00 AM. 3 out of 3 staff indicated that their “Daily Time Sheet” was correct. Records reviewed of Daily Time Sheets revealed the following: “Daily Time Sheet Caregiver 1” “Covered Dated Oct. 1-15, 2024” demonstrates that Caregiver 1 works from 7:00 AM to 7:00 PM; according to the time sheet Caregiver 1 worked on 10/15/2024 from 7:00 AM to 7:00 PM. “Daily Time Sheet Caregiver 2” “Covered Date” Oct. “1-15, 2024” demonstrates that Caregiver 2 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 2 worked on 10/15/2024 from 8:00 AM to 8:00 PM. “Daily Time Sheet” for Caregiver 3 “Covered Date Oct. 1-15, 2024” demonstrates that Caregiver 3 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 3 did not work on 10/15/2024. Resident 1’s records revealed the following: R1 requires assistance with Activities of Daily Living (ADLs) and incontinence care, and the facility agreed to “Provide Assistance on R1’s Toileting Needs” and “Provide Assistance on R1’s Activities of Daily Living” throughout R1’s “Length of Stay” through staff “Daily Observation and Monitoring.” “Regarding the allegation “Staff did not answer residents calls for assistance”, the preponderance of the evidence standard has been met therefore the allegation is substantiated.

Deficiencies cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Caregiver Daniel Aliony along with their appeal rights.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241016091424

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: 10/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/19/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided...facility require such additional staff for the provision of adequate services.	1 2 3 4 5 6 7	Staff have agreed to create a plan to follow CCR 87411 Personnel Requirements and email plan to Socorro.Leandro@dss.ca.gov. Staff have agreed to hire an overnight staff in order to attend to Resident 1’s incontinence care needs.
	8 9 10 11 12 13 14	This has not been met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not having night staff to assist R1 with their care needs, which poses a potential health, safety, and personal rights risks to persons in care.	8 9 10 11 12 13 14	Staff have agreed to email an updated LIC500 to Socorro.Leandro@dss.ca.gov.
Type B 11/19/2024 Section Cited CCR 87625(b)(2)	1 2 3 4 5 6 7	Managed Incontinence (b) In addition... the licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.	1 2 3 4 5 6 7	Staff have agreed to create a plan to follow CCR 87625 Managed Incontinence for residents in care and email plan to Socorro.Leandro@dss.ca.gov.
	8 9 10 11 12 13 14	This has not been met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring that R1’s incontinent care needs were checked at night time, which poses a potential health, safety, and personal rights risks to persons in care.	8 9 10 11 12 13 14	Staff have agreed to re-train all staff on Incontinence Care Needs for Residents in Care and email training log to Socorro.Leandro@dss.ca.gov.

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: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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