342700800-2-7-2023-27-AS-LKIG-CP5TLW-20230217135012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700800
Report Date: 01/23/2023
Date Signed: 02/07/2023 03:41:58 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2022 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221206111504

FACILITY NAME:	GOLDEN HOME FOR SENIORS		FACILITY NUMBER:	342700800
ADMINISTRATOR:	TOLON, MA MAGNOLIA M		FACILITY TYPE:	740
ADDRESS:	8701 MILO COURT		TELEPHONE:	(916) 686-2129
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	01/23/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lito Dapat		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained an injury while in care due to lack of supervision
Lack of timely medical care
Facility did not report incident to department

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Lewis arrived unannounced to the facility and met with Administrator to deliver investigation findings.

LPA Lewis has determined that the allegations are unfounded. LPA toured facility, interviewed staff and reviewed resident files. It appears that the facility have never had a resident by the name of R1. Elk Grove police was also contacted they have no recored of any calls to the adress of the facility. No supporting information to the allegations was discovered. Complaint is deemed to be unfounded at this time.

As a result of this investigation, Investigator finds allegation to be (U) Unfounded - A finding that the complaint is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted, and a copy of this report was provided via email to the facility.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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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