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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366427602
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:51:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241121084941
FACILITY NAME:GOLDEN YEARS RESIDENTIAL CAREFACILITY NUMBER:
366427602
ADMINISTRATOR:ALEXANDRU POPESCUFACILITY TYPE:
740
ADDRESS:7890 SAN BENITO STREETTELEPHONE:
(909) 335-8335
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:6CENSUS: 6DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:House Manager- Megaswati Siby and Administrator- Irene CreigntonTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff consume liquor while on shift.
Staff do not have fingerprint clearance.
Staff lock facility doors to prevent residents from leaving.
Staff insert suppositories to residents in care.
Staff did not complete required trainings.
Staff facility records are falsified.
Staff did not maintain resident records.
Residents are not provided proper food service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with House Manager Megaswati Siby and explained the purpose of the visit. The Administrator Irene Creignton was contacted regarding today’s visit. The investigation consisted of staff interviews, resident interviews, record review and facility tour.

LPA Rico conducted 4 staff interviews and 3 resident interviews.

For the allegation, Staff consume liquor while on shift.

During staff interviews 4 out of the 4 staff stated they have not witness someone drink liquor on the shift.
During resident interviews 3 out of the 6 residents stated they have not witnessed a staff drink liquor.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 56-AS-20241121084941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE
FACILITY NUMBER: 366427602
VISIT DATE: 11/22/2024
NARRATIVE
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For the allegation, Staff do not have fingerprint clearance.During staff interviews 4 out of the 4 staff stated they have fingerprint clearance. During record review, LPA Rico verify the photo identification matched the clearance letter.

For the allegation, Staff lock facility doors to prevent residents from leaving.During staff interviews 4 out of the 4 staff stated they have locked facility doors and have not locked residents inside their bedrooms. In addition, 3 out of the 6 residents stated they have not been locked inside the facility.

For the allegation, Staff insert suppositories to residents in care. During staff interviews 4 out of the 4 staff stated they have not insert suppositories to residents in care. 3 out of the 4 staff stated that only hospice nurses can provide suppositories to residents, not caregivers.

For the allegation, Staff did not complete required training's. During staff interviews, 4 out of the 4 staff stated they have completed their training's. During record review LPA verify all staff members were provided with training's.

For the allegation, Staff facility records are falsified. During staff interviews 4 out of the 4 staff stated they have not falsified facility records and have not alternated residents’ documents. During record review, LPA verify staff signatures matched facility documents.

For the allegation, Staff did not maintain resident records. 4 out of the staff stated the facility has maintain resident records. During record review, LPA observed residents residents records maintain at the facility.

For the allegation, Residents are not provided proper food service. During staff interviews, 4 out of the 4 staff stated they provided proper food service for residents in care. In addition, 4 out of the 4 staff stated they provided breakfast, lunch, dinner, and snacks in between. During resident interviews, 3 out of the 6 residents stated they receive proper food services. During facility tour, LPA observed facility menu and food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days at the facility.

Based on the evidence found during the investigation, the eight (8) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.An exit interview was conducted, and this report (LIC9099) was discussed and provided to House Manager Megaswati Siby.


SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2