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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003563
Report Date: 06/01/2022
Date Signed: 06/01/2022 02:57:16 PM

Unfounded


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
12/01/2021 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211201084008
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:
06/01/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Grace Bernadino, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Facility neglected resident resulting in worsening of pressure injuries.

Facility did not seek resident timely medical attention.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Facility Administrator Grace Bernardino to conclude and deliver the investigation findings on the above allegations. This investigation was conducted by the Investigations Branch and LPA Jacobs and consisted of site inspections to the facility to conduct interviews with the facility administrator, staff, residents and other witnesses. The Investigator obtained and reviewed copies of the resident's (R-1) files, medical reports, Law Enforcement report and additional documentation.

This investigation concluded after several inspections, interviews and record reviews that the facility did not neglect a resident (R-1) resulting in worsening of pressure injuries and did not fail to seek timely medical attention for the resident (R-1). Reviews of medical records and interviews did not provide evidence that the resident had pressure injuries or that the injuries worsened while the resident was in the home for approximately three weeks. There was also no evidence to support the allegation that the facility failed to seek timely medical attention for the resident.

Based on observations, record reviews and interviews conducted, the above allegations are determined to be without a reasonable basis and are determined to be UNFOUNDED. This report was provided to Grace Bernardino at the conclusion of this visit.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
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 3
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
12/01/2021 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211201084008

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:
06/01/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Grace Bernadino, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility rejected necessary durable medical equipment for resident.
Facility withheld oxygen from resident.
Facility did not dispense resident's medications according to doctor's orders.
Facility did not follow resident's doctor's orders
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Facility Administrator Grace Bernardino to conclude and deliver investigation findings on the above allegations. This investigation was conducted by the Investigations Branch and LPA Jacobs and consisted of site inspections to the facility to conduct interviews with the facility administrator, staff, residents and other witnesses. The Investigator and LPA obtained and reviewed copies of the resident's (R-1) files, medical reports, Law Enforcement report and additional documentation.

This investigation concluded that the facility accepted and attempted to utilize necessary durable medical equipment for a resident (R-1). The equipment was a hospital bed, Hoyer lift, oxygen and a triangle. Facility staff attempted to utilize this equipment; however the resident was reported to be non-cooperative with care much of the time. The facility staff also attempted to provide the resident with oxygen as required. Other witnesses provided different information that was not consistent with this information. Also, interviews and record reviews did not prove that the facility did not dispense resident's medications according to doctor's orders or did not follow resident's doctor's orders.

Continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211201084008
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: 06/01/2022
NARRATIVE
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The preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated 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. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies are being cited.

Exit interview held, copy of report provided to the administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3