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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320024
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:31:46 PM

Unsubstantiated


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
10/11/2024 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20241011142515
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: 6DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Caregiver - Daniel AlionyTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff pushed resident.
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 10/14/2024, The department gathered facility records.
On 10/17/2024, The department interviewed 4 out 6 residents and 3 staff.
On 10/30/2024, The department interviewed 1 out 6 residents and conducted a tour of the facility. The department attempted to interview 1 out 6 residents but the resident was sleeping.
Unsubstantiated
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)
Page: 1 of 2
Control Number 11-AS-20241011142515
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 “Facility staff pushed resident”, it is being alleged that a staff member pushed a resident multiple times to the floor. Interviews conducted revealed the following: 5 out 5 residents denied the allegation. 3 out 3 staff denied the allegation. Records reviewed revealed the following: The department requested Unusual Incident Reports (UIRs) but did not receive UIRs indicating that allegation occurred. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated.

No citations were issued.

An exit interview was conducted, and a copy of this report was left with the Caregiver Daniel Alionye.
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)
Page: 2 of 2