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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320024
Report Date: 07/02/2025
Date Signed: 07/02/2025 12:29:57 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250626102911
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:
07/02/2025
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Rodolfo Lozada, Assistant AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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On 7/2/25 Licensing Program Analyst(LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Assistant Administrator, Rodolfo Lozada and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:
On 7/2/25 LPA requested and reviewed copies of the following records: Residents file, Resident Roster, Staff roster, 30-day Eviction Notice dated, 4/11/25, Id and Emergency Contact form, Physicians Report, Admission Agreement, House Rules and Special Incident Report regarding R1. LPA Shirley interviewed Staff 1 – Staff 4 and Resident 1 and Resident 2, R3, R4 and R5 were not available for interview.


Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
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 2
Control Number 11-AS-20250626102911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 07/02/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Illegal Eviction

On 7/2/25, LPA Felisa Shirley reviewed R1’s Admission Agreement dated and signed, 2/20/25. LPA Shirley observed that R1 signed House Rules, 2/20/25. LPA Shirley reviewed all Unusual Incident reports for the month of March 2025 and observed that there were 4 incidents involving violence with staff, 1 incident involving violence with a resident and 2 incidents involving violence with his visitor. LPA Shirley reviewed 30-day Eviction Notice dated, 4/11/25 and consulted with CCLD Management and was told the notice was in compliance and within Title 22 Regulations and was accepted.

LPA interviewed staff, staff 1 – staff 4 (S-1 – S-4). LPA asked the staff, if there was a resident being illegally evicted. Of those interviewed 4 out of 4 answered no. LPA interviewed Resident 1 and Resident 2 (R-1 and R-2), R3, R4 and R5 were not available for interview. LPA asked the residents, were they being illegally evicted. Of those interviewed, 1 answered yes and the other answered no.

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. 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 Unsubstantiated.

No deficiency was cited for this allegation.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator, Rodolfo Lozada.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2