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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701175
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:33:15 PM

Substantiated


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
11/13/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20241113162728
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIIFACILITY NUMBER:
342701175
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Diana Garcia TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Personal Rights: Staff yells at residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Golden Legacy Elderly Care III RCFE on 11/14/24 at 9:00am to inform the licensee of complaint allegations mentioned above and to deliver findings.

During this investigation, LPA Gould interviewed two staff members and three residents (See confidential name list LIC-811 dated 11/14/24). one staff member denied the allegations, the other staff member interviewed provided statements that they have had conversations with identified staff member (S2) about speaking with residents in a kind and respectful manner. Based on the interviews and statements obtained during the investigation process, the allegation is substantiated. One of the three residents interviewed provided statements and audio recordings of the identified staff member cursing and making inappropriate comments to the resident. LPA also identified additional title 22 violations as part of this investigation. Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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 5
Control Number 27-AS-20241113162728
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 LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175
VISIT DATE: 11/14/2024
NARRATIVE
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The audio recordings also revealed staff S2 made statements of knowing R1 had soiled themselves in the evening by the smell and did not assist resident R1 until the following morning where S2 can be heard cursing and making inappropriate comments to R1. S2 did not assist resident in a timely manner.
LPA has identified the conduct of staff S2 as an immediate risk to residents in care and had them removed from the facility during the inspection and per licensee will not be returning to the facility. During the interviews with S2, they made false statements to LPA when denying the allegation as LPA has recordings if their statements to residents.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/13/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20241113162728

FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIIFACILITY NUMBER:
342701175
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Diana Garcia TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Physical Abuse: Staff hit resident.
INVESTIGATION FINDINGS:
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5
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9
10
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13
Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Golden Legacy Elderly Care III RCFE on 11/14/24 at 9:00am to inform the licensee of complaint allegations mentioned above and to deliver findings.

During this investigation, LPA Gould interviewed two staff members and three residents (See confidential name list LIC-811 dated 11/14/24). Two of the three residents in care denied the allegations, the alleged victim did state they were hit by S2 when performing services for R1. R1 denied any bruising. R1 states there was audio recording of being hot by S2 but LPA could not accurately identify what was described on the audio recording. Three of the residents could not be interviewed due to a medical diagnosis. S1 could not provide any corroborating evidence and denied ever witnessing such allegations.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241113162728
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 LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175
VISIT DATE: 11/14/2024
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Physical Abuse are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241113162728
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 LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2024
Section Cited
CCR
87468.2(a)(8)
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Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by
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Licensee terminated the staff member during today's inspection. Licensee agreed to conduct personal rights training for all staff members and provide documentation of completed training by Monday, 11/18/24.
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statements on audio recordings obtained during the inspection where staff S2 verbally abused resident R1 wich poses an immediate health, safety and personal rights violation to the residents in care.
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Type A
11/15/2024
Section Cited
CCR
87625(b)(3)
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Managed Incontinence: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. this requirement was not met as evidenced by audio recordings in which staff S2 is overheard making
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Licensee will submit an incontincence care plan for all residents who need assistance with incontinence by Monday, 11/18/24.
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statements that she smelled R1 had soiled self the prior evening and did not assist resident until the following morning which poses an immediate health, safety and personal rights risk to residents 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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5