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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700800
Report Date: 04/11/2024
Date Signed: 05/22/2024 12:27:47 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2024 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20240119100521
FACILITY NAME:GOLDEN HOME FOR SENIORSFACILITY NUMBER:
342700800
ADMINISTRATOR:TOLON, MA MAGNOLIA MFACILITY TYPE:
740
ADDRESS:8701 MILO COURTTELEPHONE:
(916) 686-2129
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
04/11/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ma Magnolia M TolonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident was physically assaulted while in care by an unknown adult
Staff did not provide a safe and comfortable environment for resident
Resident was disrespected by two unknown adults while in care
INVESTIGATION FINDINGS:
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AMENDED TO ADD ADDITIONAL CONTEXT LICENSEE AGREED
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 4/11/24 at 12:30pm. LPA met with William James Tolon, Administrator and stated the purpose of the visit. Magnolia Tolon, Administrator arrived within 15 minutes to assist with todays visit. During the visit on 1/22/24, LPA requested and obtained a copy of the following documents: Personnel Report LIC500, a list of staff with contact numbers, Staff work schedule, Resident roster with responsible party contact numbers, any facility progress notes for resident #1 (R1), Identification And Emergency Information (LIC601), Physician report (LIC602), Admission Agreement, Administrator Certificate(s). During this visit, LPA conducted interviews of 6 residents of which 1 had a family member present, and 4 staff during this visit. Regarding allegation(s), "Resident was physically assaulted while in care by an unknown adult", LPA obtained information through interview with R1’s Responsibly party that R1 was not assaulted, and that the complainant made it up. RP stated that when staff was assisting the resident, they bumped heads. R1 gets anxious because the nurse always comes late which put R1 in a panic and the blood pressure went up. LPA conducted interviews with R2 who stated the staff are treating them well at this facility out of the last 3 homes R2 has resided. "Staff did not provide a safe and comfortable environment for resident", LPA obtained information through interview with R1’s Responsibly party that R1 is safe at the facility but the doctor wanted a higher level of care. LPA conducted interviews with R2 who stated the staff are helpful at the facility. R3 confirmed liking being at the facility."Resident was disrespected by two unknown adults while in care", LPA obtained information through interview with R1’s Responsibly party that R1 was treated well at the facility by the wonderful staff. LPA conducted interviews with R2 who stated the staff are helpful at the facility and assists so much so that R2 can walk and write again. R3 and R4 stated staff are nice and there are no bad words used in the facility and no one was hit by anyone. R5 and R6 stated in their opinion this is about R1 who was disruptive and has now relocated. R7 stated raised voices by staff has not been heard since admittance into the facility.All interviews of R2-R7 corroborate and concur that these allegations are false which includes the interview of the family.Based on interviews and a review of R1's facility file, and facility daily notes the allegations are deemed Unfounded."The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.
Unfounded
Estimated Days of Completion: 120
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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 2
Control Number 27-AS-20240119100521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN HOME FOR SENIORS
FACILITY NUMBER: 342700800
VISIT DATE: 04/11/2024
NARRATIVE
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Based on interviews and a review of R1's facility file, and facility daily notes the allegations are deemed Unfounded.

"The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint."

Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2