198320027-7-11-2025-11-AS-UCOL-DKRPQY-20250821113155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320027
Report Date: 07/11/2025
Date Signed: 07/11/2025 02:58:12 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
07/08/2025 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250708112102

FACILITY NAME:	GOLDEN CARE LIVING IV		FACILITY NUMBER:	198320027
ADMINISTRATOR:	GRADNEY, STEPHEN		FACILITY TYPE:	740
ADDRESS:	27711 HAWTHORNE BLVD		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	07/11/2025
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Kathleen Mantes, Caregiver		TIME COMPLETED:	03:26 PM

ALLEGATION(S):

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Staff inappropriately restrained resident resulting in injury.
Staff handled residents in a rough manner.
Staff did not ensure resident a safe environment while in care.

INVESTIGATION FINDINGS:

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On 07/11/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at the facility. LPA was met by staff number two, Kathleen Mantes - Caregiver (S2), and the purpose of the visit was explained.
Investigation consisted of the following: On 07/10/25 LPA obtained Facility record paperwork as follows: Medication Administration Record (MAR) of resident one, two and three (R1 through R3) (dated: 06/01/25 through 07/10/25), Physician's Report for R1&R3 (dated: various). LPA interviewed four (4) residents (R1 through R4), three (3) staff (S1,S2&S3) and one witness (W1). LPA and S2 toured the physical plant. R3 was not available for LPA's interview, due to R3 currently resting. R4 was not available for LPA's interview, due to R4's medical condition.On 07/11/25 LPA conducted a subsequent visit to obtain further records, listed as follows: Identification and Emergency information of R1 through R4 (dated: 08/30/24 through 06/26/25) and R2's physician's report. R2's updated physician report has not been provided to the facility, due to R2's family time constraints. LPA has conducted a case management, please see LIC809. Report continues, see LIC9099-C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250708112102

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: 07/11/2025

NARRATIVE

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R1's two (2) discharge paperwork from hospital #1 (H1) and hospital #2 (H2), shift crossover notes (dated: 06/24/25 through 07/05/25) and LPA observed R1's injuries. Please see LIC813-C. LPA attempted to interview R3 once more, R3 was not available for interview due to current medical condition. LPA attempted to interview R4 & R5 and both were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview request.
Investigation revealed the following: Regarding the allegation, "Staff inappropriately restrained resident resulting in injury.", it is being alleged that a resident had redness on both forearms from being restrained by staff. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1&R2) and W1 have disagreed the allegation has taken place at the facility. R1 stated, "Two (2) of the guys near the hospital, grabbed me and stomped all over me.", which indicate the allegation has not taken place at this facility. Based on record reviews, LPA observation(s) and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation, "Staff handled residents in a rough manner.". It is being alleged that a resident was bruised by staff. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1-R2) and W1 have disagreed the allegation has taken place at this care facility. R1 stated, "I guarantee to you that they didn’t do that here. That was at the hospital.", which indicates that the staff at this care facility are appropriately trained to care for the elderly. Based on record reviews, LPA observation(s) and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Report continues, see LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250708112102

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: 07/11/2025

NARRATIVE

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Regarding the allegation, "Staff did not ensure resident a safe environment while in care.". It is being alleged that a resident has been "beat up" at the home. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1&R2) and W1 have disagreed the allegation has taken place at this care facility. R1 stated, "It's so good to be clean and safe here." and "Time here is wonderful, the staff are nice and the food is great. Everything is great here!". Based on LPA observation(s), record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There have been zero (0) deficiencies cited during today's visit.

An exit interview was held with staff two, Kathleen Mantes - Caregiver (S2), and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC9099 (FAS) - (06/04)

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