<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003563
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:18:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/06/2021 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20210806160338
FACILITY NAME:GOLDEN YEARS CARE HOME IIFACILITY NUMBER:
347003563
ADMINISTRATOR:BERNARDINO, GRACE C.FACILITY TYPE:
740
ADDRESS:8786 SILVERBERRY AVENUETELEPHONE:
(916) 681-3726
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Grace BernadinoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not changing the resident's breif.
Resident has pressure injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10-06-2021 at 8:25 am, Licensing Program Analysts (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Grace Bernadino and explained the purpose of today's visit.

During the course of the investigation, LPA Martinez conducted interviews, toured the facility, and reviewed facility documents. LPA Martinez reviewed R1's medical file. R1's medical file did not contain a home health service plan or a written care responsiblity agreement between the licensee and home health agency. Moreover, R1's facility records do not indicate R1 had open wounds or pressure injuries. LPA Martinez interviewed staff 1 (S1), and S1 reported R1 did not have open sores or pressure injuries. S1 reported R1 had redness on the sacral bone. Adittionally, LPA Martinez was informed by facility staff that R1's breif is changed four times a day and is checked on every 2 hours. Moreover, R1's file contained a Self Care Deficit service plan dated 02/21/2021, which states, "provide incontinence care every 2-3 hours as needed...apply barrier cream during each incidence of care." However, R1's facility file did not contain bowel and bladder charting notes.
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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-20210806160338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN YEARS CARE HOME II
FACILITY NUMBER: 347003563
VISIT DATE: 10/06/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Furthermore, LPA Martinez conducted an interview with witness 3 (W3). W3 reported the facility has been providing satisfactory care to R1. W3 reported at this time, there are no concerns with the care that is being provided to R1. Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was given to the facility at the end of this visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2