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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320027
Report Date: 05/14/2024
Date Signed: 05/14/2024 03:46:06 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, 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
05/09/2024 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20240509102813
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: 3DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Cathy Espino/AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not distribute resident's medication as prescribed
INVESTIGATION FINDINGS:
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On 5/13/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Cathy Espino/Administrator. LPA explained the purpose of this visit.


Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1). LPA reviewed the following documents: Copies of the Medication Administration Records-MARs for R#1-R#4 for the months of May and March 2024 and pictures taken by LAP of resident’s medications (R#1-R#4).


Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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 7
Control Number 11-AS-20240509102813
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 IV
FACILITY NUMBER: 198320027
VISIT DATE: 05/14/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff do not distribute resident's medication as prescribed.

The details of the complaint alleged that facility staff are not distributing resident’s medications as prescribed.


During the records review, LPA Iniguez reviewed the following: For (R#1) MARs in May 2024, facility staff did not document three prescribed medications on the 4th, 5th, and 6th days. (R#1)’s prescribed medications stated they were to be taken daily. One medication was prescribed to be taken twice a day, but there is only documentation in the MARs that the medication was given once from May 1st to the 14th.

For March 2024, facility staff must document MARs for (R#1), a medication prescribed at bedtime, on March 1st, 2nd, 3rd, 4th, 5th, and 6th. (R#2)’s Medication Administration Records (MARs) for the month of May 2024 showed that facility staff documented the days of the 1st, 2nd, and 3rd of May; the rest of the days are blank. (R#2)’s prescribed medications state that they are to be taken once a day.

For March 2024 MARs for (R#2), LPA observed that facility staff needed to document medications given on the 10th, 11th, 12th, 13th, 14th, and 15th. (R#2) ’s prescribed medications state that they ought to be given daily. (R#3)’s Medication Administration Records-MARs for March 2024 showed that facility staff did not document for the whole month if they prescribed medication. (R#3)’s prescribed medication is to be given 3x daily; MARs showed medication was given twice only by facility staff.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20240509102813
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 IV
FACILITY NUMBER: 198320027
VISIT DATE: 05/14/2024
NARRATIVE
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(R#4)’s Medication Administration Records-MARs for April 2024 showed that facility staff did not document if prescribed medication was given on the 10th, 11th, 12th, 13th, 14th, and 15th of the month. (R#4)’s prescribed medication states to be given twice daily before meals.

For March 2024 MARs for (R#4), LPA observed that facility staff needed to document medications given on the 28th, 29th, 30th, and 31st. (R#4) Prescribed medications are to be given daily.

In addition, LPA reviewed (R#1-R#3) Physicians Report for Residential Care Facilities for the Elderly (RCFE) LIC 602A. The report shows that all 3 residents are not able to administer their own Prescription Medications.

During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.)

An exit interview was conducted, and a copy of the Complaint Report was given to Cathy Espino/Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20240509102813
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 IV
FACILITY NUMBER: 198320027
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87465(a)(6)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
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Licensee will ensure facility staff documents medications given to/refused by residents at all times. As plan of correction, licensee will re-train facility staff on how to document medications on MARs properly. A copy of this training will be sent to LPA before POC due date.

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Based on observations and records review, the licensee did not comply with the section cited above as residents (R#1-R#4) medications were not checked off on MARs for the months of May and March 2024 and there is no documentation detailing if residents took or refused their prescribed medications which poses/posed a potential health, safety, or personal rights risk to persons 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: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
05/09/2024 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20240509102813

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: 3DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Cathy Espino/AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
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9
Staff do not ensure that a resident's incontinence needs are met
INVESTIGATION FINDINGS:
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On 5/13/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with /Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Residents’ interviews (R#1-R#3) and Witness interview(W#1). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#3) Identification and Emergency Information, (R#1-R#3) Admissions agreements, (R#1-R#3) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#4) Medication Administration Record (MAR) for the months of March, April, and May 2024.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20240509102813
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 IV
FACILITY NUMBER: 198320027
VISIT DATE: 05/14/2024
NARRATIVE
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Investigation Revealed the Following:


Allegation: Staff do not ensure that a resident's incontinence needs are met.

The details of the complaint alleged that facility staff are not ensuring that resident’s incontinence needs are meet.

During a physical tour of the facility, the LPA inspected (R#1-R#3) changing supplies. The LPA observed that each resident had enough supplies for at least two weeks. The items observed by the LPA included disposable adult diapers, disposable bed pads, and cleaning lotions used for continence care. Additionally, upon arrival at the facility, the LPA observed two caregivers present.

During the records review, the LPA observed the Personnel Report—LIC 500 and noted that two caregivers were scheduled at the facility during the daytime and two for nighttime.

During an interview with the administrator (A#1), she stated that there are always two caregivers at the facility during the day and at night. Additionally, (A#1) indicated that the facility staff are meeting the residents' continence care needs and that there are enough supplies for them to use. Also, (A#1) stated that no resident in care has ever been left in a soiled diaper for an extended period. The facility has a policy that requires changing residents' diapers three times per day or as needed.

During interviews with residents (R#1-R#3), (2) out of (3) stated that there are always two caregivers on site and their continence needs are being met. In addition, (2) out of (3) indicated that they had never been left in a soiled diaper for an extended period.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20240509102813
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 IV
FACILITY NUMBER: 198320027
VISIT DATE: 05/14/2024
NARRATIVE
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During an interview with Witness 1 (W#1), they stated that there are always two caregivers every time they visit (R#3). Also, (W#1) stated that (the facility is meeting (R#3) 's continence needs; they said, "I am always at the facility; “I will know if (R#3) is not being changed”. In addition, (W#1) stated that (R#3) has never been left on a soiled diaper for an extended period.

During interviews with staff (S#1-S#2), (2) out (2) stated that there are always two caregivers in the day and night. Also, (2) out of (2) staff said that they are meeting the residents in care continence needs. They both stated that they change the residents thrice a day or as needed and check them every two hours. In addition, (2) out of (2) state that they have never left a resident on a soiled diaper for an extended period.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.


An exit interview was conducted, and a copy of the Complaint Report was given to Cathy Espino /Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7