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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320027
Report Date: 07/20/2021
Date Signed: 07/20/2021 01:19:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/12/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210712124146
FACILITY NAME:GOLDEN CARE LIVING IVFACILITY NUMBER:
198320027
ADMINISTRATOR:GRADNEY, STEPHENFACILITY TYPE:
740
ADDRESS:27711 HAWTHORNE BLVDTELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:STEPHEN GRADNEYTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff failed to maintain complete resident records
Facility staff failed to meet the residents needs.
INVESTIGATION FINDINGS:
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On 07/20/2021 around 12:00 noon Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation
to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Stephan Gradney. The Investigation consisted of the following: On 07/20/2021 LPA Calderon interviewed Administrator Stephan Gradney and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Physicians Report, needs and service plan, SIR reports for complaint. On 07/24/2021 LPA Calderon interviewed S2-S3 for complaint and LPA Calderon interviewed R1-R3 for complaint. On 07/20/2021 LPA Calderon reviewed medical records for R1. On 07/15/2021 LPA Calderon interviewed witness for complaint.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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-20210712124146
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027
VISIT DATE: 07/20/2021
NARRATIVE
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Allegation: Facility staff failed to maintain complete resident records.
It is alleged on 07/20/2021 than Facility staff failed to maintain complete resident records: Witness states that fire department was called to assist in lift of resident 1. Witness states that staff was not able to move resident and that staff did not have complete medical records. On 07/20/2021LPA Calderon interviewed S1 that stated to have no knowledge of any issues with resident 1 or that staff could not move or lift resident 1 out of his bed. S1 states that staff did not submit an Special Incident report for this complaint or that the fire department showed up to his facility. S1 did not know that the resident DNR was not signed and that records were not the same. Staff was not able to give medical information for R1 while being taken to the hospital. On 07/20/2021 LPA Calderon interviewed S2-S3 who both confirm that the medical records were not complete and the DNR was not signed at the time the fire department showed up. On 07/20/2021 LPA Calderon reviewed medical reports for R1, confirmed the records for R1 were incomplete during the time the fire department came out to assist R1.

Allegation: Facility staff failed to meet the resident’s needs.
Witness states that fire department was called to assist in lift of resident 1. Witness states that staff was not able to move resident and that staff did not have complete medical records. On 07/20/2021LPA Calderon interviewed S1 that stated to have no knowledge of any issues with resident 1 or that staff could not move or lift resident 1 out of his bed. S1 states that staff did not submit an Special Incident report for this complaint or that the fire department showed up to his facility. S1 did not know that the resident DNR was not signed and that records were not the same. Staff was not able to give medical information for R1 while being taken to the hospital. On 07/20/2021 LPA Calderon interviewed S2-S3 who both confirm that the medical records were not complete and the DNR was not signed at the time the fire department showed up. On 07/20/2021 LPA Calderon reviewed medical reports for R1, confirmed the records for R1 were incomplete during the time the fire department came out to assist R1. Based on interviews conducted the facility staff and Administrator were not fully aware of R1 needs. The facility staff needed assistance from the fire department to transfer R1 and were unable to provide much information to the fire department.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20210712124146
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027
VISIT DATE: 07/20/2021
NARRATIVE
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Based on LPAs observations and interviews which were conducted and the records that were
reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s)
is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are
being cited on the attached LIC 9099D.

A face to face exit interview was conducted with Administrator Stephen Gradney, and a hard copy was
provided by hand for record
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20210712124146
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2021
Section Cited
CCR
87506(A)
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87506 Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement was not met as evidenced by
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Adminstrator will conduct additional training of statt regarding records and the accuracy of same.
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Based on records reviewed and interviews
conducted the licensee failed to ensure staff kept accuriate records. This poses a health &
Safety risk to residents in care.

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Type B
07/30/2021
Section Cited
CCR
87606(a)(f)(1)(a)
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87606 Care of Bedridden Residents:Unless otherwise specified....:To accept or retain a bedridden person, a facility shall ensure the following:The facility's Emergency Disaster Plan....This requirement was not met as evidenced by
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Administrator will provide action plan to move resident in care of emergency and provide training within 7/30/2021
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Based on records reviewed and interviews conducted the licensee has not provided staff regarrding the care for a bed ridden client. This poses a healh & safety risk to resident 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: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4