GOLDEN CARE LIVING III

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requierment was

Deadline recorded: Oct 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615 (a) Prohibited Health Conditions: Persons who require health services for or have a health condition including, Stage 3 and 4 pressure injuries shall not be admitted or retained in a residential care facility for the elderly. Resident 1 (R1) was receiving treatment from Legend Home Health Services for stage 3 and 4 unstageable pressure injuries. R1 was not on hospice at the time of admission. The violation poses a potential health and safety risk to residents in care.

Official plan of correction

The Licensee will review and train staff on Prohibited Health Condition and comply, and ensure that the facility will not admit or retain any residents with a health condition of Stage 3 or 4 pressure injuries. The deficiency was corrected prior to today's visit.

Deadline recorded: Aug 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having an outside side door in disrepair and the kitchen window did not have a screen which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2025 Plan of Correction The licensee has agreed to fix the outside side door and place a screen on the kitchen window. The licensee will submit pictures to Socorro.Leandro@dss.ca.gov as proof of correction.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in not providing Resident 1 with medications as prescribed (R1 has a medication that is prescribed twice a day but the staff have only been providing this medication once a day) which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2025 Plan of Correction The licensee has agreed to provide Resident 1 with medication as prescribed. The licensee will send a picture of the updated Medication Record for Resident 1 to Socorro.Leandro@dss.ca.gov.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided...facility require such additional staff for the provision of adequate services. This has not been met as evidenced by: Based on interviews and record review, the licensee did not have staff working between 8PM and 7AM to provide R1 with their care needs, which resulted in R1 developing a stage 3 pressure injury while in care.

Official plan of correction

On 10/15/2024, Licensee provided facility with overnight staff. The Administrator has agreed to create a plan to follow CCR 87411 Personnel Requirements regarding services necessary to meet the needs of residents who require rotation every 2 hours and to follow Home Health instructions for residents in care. Email plan to Socorro.Leandro@dss.ca.gov

Deadline recorded: Feb 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided...facility require such additional staff for the provision of adequate services. This has not been met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not having night staff to assist R1 with their care needs, which poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Staff have agreed to create a plan to follow CCR 87411 Personnel Requirements and email plan to Socorro.Leandro@dss.ca.gov. Staff have agreed to hire an overnight staff in order to attend to Resident 1’s incontinence care needs. Staff have agreed to email an updated LIC500 to Socorro.Leandro@dss.ca.gov.

Deadline recorded: Nov 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(2)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence (b) In addition... the licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This has not been met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring that R1’s incontinent care needs were checked at night time, which poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Staff have agreed to create a plan to follow CCR 87625 Managed Incontinence for residents in care and email plan to Socorro.Leandro@dss.ca.gov. Staff have agreed to re-train all staff on Incontinence Care Needs for Residents in Care and email training log to Socorro.Leandro@dss.ca.gov.

Deadline recorded: Nov 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This has not been met as evidenced by: Based on record review/interview (R2-R5) are incontinent and requires assistance with diaper changes. Facility did not have a night staff to meet (R2-R5) needs after 7pm. This violation which poses a potential health and safety to residents in care.

Official plan of correction

Licensee/Administrator have agreed to hire an overnight staff in order to attend to residents' needs while in care. Administrator will send an updated LIC500 to LPA Dabuet, via email, at Ernand.Dabuet@dss.ca.gov

Deadline recorded: Oct 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on ecord review, the licensee did not comply with the section cited above in having an expired liability insurance which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2024 Plan of Correction Licensee will renew liability insurance and email proof of correction to Socorro.Leandro@dss.ca.gov.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having mold in bathroom 1, bedroom 2’s drawer in disrepair, kitchen cabinet in disrepair and no shower head in bathroom 3, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2024 Plan of Correction Mold in bathroom 1, bedroom 2’s drawer in disrepair, kitchen cabinet in disrepair and no shower head in bathroom 3. Licensee will fix items listed above and email proof of correction to Socorro.Leandro@dss.ca.gov

Official classification

Type B

Official code

1569.319(a)

Regulation authority

HSC

What the official deficiency says

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in having a videoconferencing device dedicated for resident use, which poses a personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2024 Plan of Correction Licensee will have a videoconferencing device dedicated for resident use in the facility. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above, LPA observed two empty medication bottles for Resident 5, there was no documentation on file indicating that facility attempted to assist R5 with attaning R5's medication, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2024 Plan of Correction Licensee will assist R5 with attaining their medication. Licensee will create a plan to ensure that R5 does not run out of medication. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Official classification

Type B

Official code

87625(b)(2)(3)

Regulation authority

CCR

What the official deficiency says

87625 (b) (2) (3) Managed Incontinence: The licensee shall be responsible for ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence odors from incontinence. On Sunday, June 23, 2024 residents 1 and 2 were left in soiled diapers for an extended period because one of the staff did not report to work and was a no-show The violation poses a potential health and safety risk to residents in care.

Official plan of correction

The deficiency was corrected prior to today's visit. The staff ensured that incontinent residents were kept clean and dry, the facility remained free of odors, and incontinent residents were checked regularly during known periods of incontinence.

Deadline recorded: Jul 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

1569.2 (c) Health and Safety Code: The facility staff is responsible for providing care and supervision to meet residents’ needs, including assistance with daily living activities such as personal care, dressing, bathing, and managing incontinence of bowel and/or bladder. The staff failed to meet the resident’s daily personal care needs. The violation poses a potential health and safety risk to residents in care.

Official plan of correction

The deficiency was corrected prior to today's visit. The facility ensures sufficient and competent staff are available to provide the necessary services needed to meet residents' needs.

Deadline recorded: Jul 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This was not met as evidenced by: Based on interviews with six witnesses (W1-W6), it was revealed that Healing Care Hospice agency was the selected and preferred hospice agency to provide hospice care services to R1. Two out of six witnesses revealed the visiting nurse from Healing Care Hospice agency attempted to visit and assess R1 on 12/30/2022 around 6:00 pm, but facility staff denied the nurse an entry to the facility. W5 revealed R1 was transferred to another facility on 1/5/2023 due to the facility’s refusal to use R1’s preferred and contracted hospice agency. This poses an immediate risk to health, safety and/or personal rights to residents in care.

Official plan of correction

The administrator shall review Section 87468.1 of Title 22 and shall self-certify understanding of this provision. Administrator shall conduct in-service training to staff about resident’s personal rights indicated in this section of Title 22. Administrator shall submit proof of corrections to CCLD by faxing to 424-544-1016 by the POC due date.

Deadline recorded: Jan 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above, LPA did not observe Health Screening Reports (LIC 503) for Staff S2, S3, S5, S6, and S7, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction The administrator will obtain Health Screening Reports (LIC 503) for Staff S2, S3, S5, S6, and S7. Proof of correction will be submitted via email to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above, LPA did not observe a needs and service plan for residents 2 and 5, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction Adminstrator will complete needs and service plan for residents 2 and 5 and submit proof of correction to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on recird review, the licensee did not comply with the section cited above, LPA did not observe a physician's report for resident 4, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction Administrator will retrieve a physician's report for resident 4 and email proof of correction to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above, LPA did not observe results of TB examination for R2, R3, and R5, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction Administrator will obtain TB examination for R2, R3, and R5 and email proof of correction to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above, LPA was unable to review onsite fire drills, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction Administrator will conduct quarterly fire drills, maintain record on site, and email proof of correction to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above during today's visit, LPA observed bleach in the backyard, knives in the kitchen drawer, and cleaning solution under the kitchen sink and in the garage accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction The administrator agreed to store the above said items and ensure that they are inaccessible to residents in care. The administrator also agreed to create a plan to ensure the future compliance to Title 22 regulation 87309(a) Storage Space. Proof of correction will be submitted to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in two out of five staff records were unavailable on September 1, 2023 visit, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction Administrator will ensure that Personnel Records (listed on LIC 500 Personnel Report) are complete and on site. Administrator will email proof of Personnel Report and missing staff records to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

1569.319(a)

Regulation authority

HSC

What the official deficiency says

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and interview of staff, the licensee did not comply with the section cited above, during today's visit staff stated that the facility does not provide common internet access device for residents' use, which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction Administrator will ensure that residents will have access to at least one internet access device that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions. Proof of correction will be emailed to regina.cloyd@dss.ca.gov

Official classification

Type B

Official code

87625(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (8) Privacy shall be afforded when care is provided. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview of S3, the licensee did not comply with the section cited above in two out of five residents who shared room number three are not afforded privacy during routine hygiene care which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2023 Plan of Correction Administrator will create a plan to ensure that residents are afforded privacy during routined hygiene care. Proof of correction will be emailed to regina.cloyd@dss.ca.gov