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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294287
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:11:50 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2022 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20221107101910
FACILITY NAME:GOLDEN HILLS CARE HOMEFACILITY NUMBER:
435294287
ADMINISTRATOR:BASILIO, CARLOFACILITY TYPE:
740
ADDRESS:2845 WESTBRANCH DRIVETELEPHONE:
(408) 528-1325
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 4DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Licensee/Administrator, Carlo BasilioTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff over medicated resident.
Staff did not meet the needs of the resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Licensee/Administrator, Carlo Basilio and stated the purpose of today’s visit.

On 11/7/2022, the Department received a complaint with the above allegations. On 11/15/2022, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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 26-AS-20221107101910
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 435294287
VISIT DATE: 09/30/2024
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
Page 2 of 2.

Staff over medicated resident.
It was alleged that the facility staff were administering “as needed” (PRN) medication ever day to resident R1.
On 11/15/2022, the Department conducted interviews with 2 staff (S1-S2) and ADM. Three out of three staff stated the facility staff administered medications as prescribed. ADM stated Hospice nurse audited R1’s medications and did not find anything.

Based on review of R1’s medication list provided by hospice agency, R1 was administered 9 routine medications and 9 as needed (PRN) medications. Based on review of R1’s facility file, facility staff had retained physician’s orders provided by hospice physician on new medication orders effective on 10/18/2022 and 10/21/2022.

Staff did not meet the needs of the resident.
It was alleged that the facility staff did not provide assistance with ADLs.

On 11/15/2022, the Department conducted interviews with 2 staff (S1-S2) and ADM. 3 Out of 3 staff stated the facility staff provided assistance with ADLs, which including taking R1 on walks, assisting R1 at night by cooking food when R1 requested and administering medications as prescribed by physician.

Based on review of R1’s Preplacement Appraisal Information dated 10/14/2022 which was completed by R1’s Responsible Party, R1 had neurocognitive disorder and needed assistance with bathing, hair care, personal hygiene, medication, incidental health an medical care.

This complaint was closed without investigation.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee/Administrator, Carlo Basilio and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2