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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701261
Report Date: 04/24/2024
Date Signed: 04/24/2024 11:13:25 AM

Unsubstantiated


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
03/04/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240304171144
FACILITY NAME:GOLDEN HERITAGE SENIOR CAREFACILITY NUMBER:
342701261
ADMINISTRATOR:BIGELOW, YELENAFACILITY TYPE:
740
ADDRESS:37 MOSSGLEN CIRTELEPHONE:
(916) 631-0694
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 6DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Yelena BigelowTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff pushed resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Yelena Bigelow and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Bigelow, a staff member (S1) and four residents (R1, R2, R3, R6).

During an interview, Bigelow said that a resident (R1) had been experiencing unusual behaviors during the time period of March 2, 2024 through March 4, 2024. Bigelow said during this time period, R1 had poured water all over the facility’s floors, was urinating in the facility, and on March 4, splashed water on S1. Afterward, R1 claimed that S1 had pinned R1 on the floor, according to Bigelow. Bigelow said R1 was diagnosed with a urinary tract infection after being sent out to the hospital. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
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-20240304171144
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 HERITAGE SENIOR CARE
FACILITY NUMBER: 342701261
VISIT DATE: 04/24/2024
NARRATIVE
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During an interview, LPA Moleski asked R1 about the events on March 4, 2024. R1 said there was “water everywhere.” R1 said that S1 had pushed R1, but also said that R1 had fallen. LPA Moleski did not observe any unusual injuries on R1 during this interview which would indicate physical abuse. LPA Moleski reviewed R1’s file. R1 is diagnosed with bipolar disorder, but does not have dementia, according to R1’s LIC 602 dated 1/18/24.

During an interview, S1 said that R1 splashed water on S1 on March 2, 2024, then did so again on March 4, 2024. S1 said that after this second incident, R1 grabbed a plate and raised it to strike S1. S1 said S1 grabbed R1’s wrist and removed the plate from R1’s hand, but did not push R1. S1 said R1 had not fallen during the incident. S1 said the incident occurred in the facility’s living room, but said no others were present to witness the events as described. S1 said police were called and R1 was later sent out to the hospital.

In interviews, R2, R3, and R6 did not report having been physically abused by staff while living at the facility.

The department has determined the following as it relates to the allegation that staff pushed a resident:

Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Bigelow.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2