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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700162
Report Date: 10/17/2023
Date Signed: 10/25/2023 12:04:15 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
09/12/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230912162010
FACILITY NAME:GOLDEN AGE HOME CARE VIIIFACILITY NUMBER:
502700162
ADMINISTRATOR:KENROY ANDERSONFACILITY TYPE:
740
ADDRESS:3013 QUEENS GATE COURTTELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 6DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marinela Placintar TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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On 10/17/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Kenroy Anderson and explained the purpose of this visit. The purpose of this visit is to delivery complaint findings for the allegation above.

Current census was 6. A brief interview with FDA Anderson was conducted.

It was alleged that a staff member hit a resident. During the course of this investigation LPA reviewed facility records and conducted interviews. Based on interviews conducted it was learned that it was alleged that an individual who was delivering medication witnessed a staff member hit a resident. It was reported that the individual delivering medication peaked into the window and stated that the resident was being fed at the time and pushed the staff member’s hand away and in response the staff member hit the resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
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-20230912162010
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 AGE HOME CARE VIII
FACILITY NUMBER: 502700162
VISIT DATE: 10/17/2023
NARRATIVE
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It was learned through this interview that this individual could not recall where the resident was hit. An interview with facility staff was conducted. It was learned through staff interviews that the facility conducted an internal investigation and found no evidence to show that the resident was hit. Staff members present at the time of the incident denied hitting any residents. LPA also conducted an interview with the resident, however, due to medical conditions could not complete the interview. LPA reviewed facility records of pictures that were taken after the alleged incident where it was observed that the resident did not have any redness, marks or bruising around their face or body. Based on the information gathered, it is unclear if the staff member hit the resident.

Based on information provided through interviews and records reviewed, this allegation is deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2