198320024-5-10-2025-11-AS-SCIS-DL6T3K-20250903142228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320024
Report Date: 05/07/2025
Date Signed: 05/10/2025 11:11:42 AM

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
01/31/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20240131103123

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: 5	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jeremy Nebres		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident #1 went to hospital with serious wound issues:Stage 3, Stage 4 and unstageable wounds

INVESTIGATION FINDINGS:

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On 05/07/2025 at 10:00 A.M., the Department conducted a subsequent visit to gather information regarding the above allegation. The Department met with Caregiver/Staff Jeremy Nebres, and spoke to Licensee Angelique S. Gradney via and the purpose of the visit was explained. LPA was granted entry to the facility.

The investigation consisted of the following: On 05/07/2025, interviews were conducted with staff members #1-2 (S1-S2) and residents #2-6 (R2-R6). Resident #1 (R1) no longer resides at the facility. 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 requested and reviewed the resident's records and asked for copies of the following documents: Personnel report (Dated 05/07/2025), Resident Roster (Dated 05/07/2025), Admission Agreement (Dated 10/14/2023), Identification and Emergency Information (Dated 10/14/2023), Physician's Report (Dated 10/19/2023), Medical Assessment (12/21/2022), Medication Administration Records (MARs), (Dated 10/14/2023 -01/25/2024). See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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 3

Control Number 11-AS-20240131103123

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: 05/07/2025

NARRATIVE

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Continued LIC9099-C page 2

Appraisal Need and Services Plan (Dated 10/12/2023), Safeguards for Cash Resources, (Dated 10/14/2023) Preplacement Appraisal Information (Dated 10/14/2023), Safeguards for Property Valuables (Dated 10/14/2023), Personal Rights (Dated 10/14/2023), Consent Forms (Dated 10/23/2023), Progress Notes (10/14/2023 - 01/25/2024), and Legend Home Health Medical Records (Dated 02-18-2023 - 01/25/2024)

Investigation Reveals the following:
It was reported that the resident #1 (R1) arrived at Torrance Memorial Medical Center's Emergency Room on January 25, 2024, with serious wound issues, including stage 3, stage 4, and unstageable pressure ulcers on the heel, leg, and lower back. Staff members #1 and #2 (S1-S2), interviewed, confirmed the allegation.

S1 and S2 stated that R1 had been receiving wound care treatment prior to admission and was referred from a facility that was closing. Upon admission to Golden Care Living III, the resident presented with a pre-existing decubitus ulcer in the buttocks and groin area. R1 was referred to Legend Home Health, Inc., for ongoing wound care treatment. The nurse and primary care physician remained in constant communication throughout the resident's entire stay at the facility.

Allegation: Resident #1 went to the hospital with serious wound issues: Stage 3, Stage 4, and unstageable wounds.
On 05/07/2025, the Department interviewed two staff members #1 and #2 (S1-S2), regarding the alleged allegation that resident #1 (R1) was admitted to the hospital due to serious wound issues: Stage 3, Stage 4, and unstageable wounds. 2 out of 2 staff stated it is true resident #1 (R1) was admitted to the hospital with serious wound complications. S1-S2 stated that R1 was admitted to the facility on 10/14/2023 and was already receiving treatment for pressure wounds at the time of admission from Home Health, from 02/17/2023 - 01/25/2024, before the resident was admitted to Golden Care Living III.

S1 and S2 states, R1 was hospitalized on 01/25/2024 while under the care of Legend Home Health Care, Inc., due to worsening wound conditions, including Stage 3, Stage 4, and unstageable wounds.

See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240131103123

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: 05/07/2025

NARRATIVE

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Continued LIC9099-C page 3

On 05/05/2025, the Department interviewed five residents. Residents #2 through #6 (R2-R6), regarding the alleged allegation that resident #1 (R1) was admitted to the hospital due to serious wound issues: Stage 3, Stage 4, and unstageable wounds. The Department was unable to interview Resident #1 due to R1 no longer residing at the facility as of 01/25/2024. R2-R6 stated that they had no knowledge of the complaint allegation. 5 out of 6 residents interviewed denied the allegation and stated that they did not witness any residents with serious wounds. R2-R6 stated they had no concerns or problems and were happy with the care and supervision provided. R2-R6 stated that the staff are doing an excellent job of maintaining their living conditions at the facility.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

There were no deficiencies cited. LPA Bunker provided Caregiver/Staff Jeremy Nebres with copies of the Complaint Investigation Reports LIC-9099 and LIC-9099Cs.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

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