Golden Hill Homes

Type of visit: Required - 1 Year

On 4/7/2026 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Fathma Ansari and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedroom are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms was measured at 116.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/24/2026. First aid kit was observed to be complete. Emergency Disaster plan last reviewed on 2/1/2026. Emergency disaster drill was last conducted on 3/1/2025. At 10:00 AM, LPA reviewed 4 of 4 residents records. At 10:30 AM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 4/20/2026: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 7, 2026

Type of visit: Required - 1 Year

On 3/26/2025 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Fathma Ansari and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedroom are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms was measured at 117.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/19/2025. First aid kit was observed to be complete. Emergency Disaster plan last reviewed on 3/26/2025 .Emergency disaster drill was last conducted on 3/1/2025. At 9:00 AM, LPA reviewed 6 of 6 residents records. At 9:30 AM, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 26, 2025

Allegation investigated: Questionable Death

On 5/3/2024 at 12:50 PM, Licensing Program Analyst (LPA), A. Gomez arrived unannounced to deliver complaint findings for the allegations above. LPA met with Administrator, Fathma Ansari and explained the reason for the visit. Allegation: Questionable Death On 2/28/2024, The Department received a complaint regarding the questionable death of R1. During the course of the investigation, the Department obtained and reviewed R1’s records including but not limited to: R1’s admission agreement, physician’s report, care plan, hospice notes, medication log, incident reports, and death certificate. Report Continues on LIC9099-C Unfounded R1 was admitted to the facility on 12/26/2023 on hospice care with Hope Hospice. R1 was recertified for hospice on 12/6/2023 with life expectancy of six months or less due to terminal diagnosis and co-morbidities. Physicians Orders for Life-Sustaining Treatment (POLST) dated 4/17/2023 was marked as do not resuscitate (DNR) by W1 and hospice care plan dated 12/26/2023 has advanced directives marked as DNR, no tube feeding, no transfer to acute hospital, and no lab work or x-rays without Hope hospice approval. On 2/18/2024 unusual incident report indicated R1 was transferred from the facility to San Ramon Regional Medical Center via paramedics for agitation and restlessness. Facility staff S1 contacted Hope Hospice to inform of transfer despite staff relaying that R1 was on hospice. Hospice witness W2, contacted the attending physician and R1 was transferred back to the facility. R1 passed away on 2/23/2024. The Department obtained certificate of death from Contra Costa County for R1 listing the immediate cause of death as cardiopulmonary arrest and underlying causes protein calorie malnutrition, failure to thrive, and Alzheimer’s dementia. Other significant conditions that contributed to R1’s death were listed as colon cancer with colostomy and atrial fibrillation. There are no questionable circumstances surrounding R1’s death. This agency has investigated the complaint alleging Questionable Death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, May 3, 2024 · control 15-AS-20240228151212

Type of visit: Required - 1 Year

On 4/09/2024 at 10:15 AM, Licensing Program Analysts (LPAs) A. Gomez and A. Gharachorloo arrived unannounced to conduct Required 1 Year Annual inspection. LPAs met with Administrator, Fathma Ansari and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedroom are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms was measured at 113.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/04/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 1/28/2024. At 10:30 AM, LPAs reviewed 5 of 5 residents records. At 10:50 AM, LPAs reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 9, 2024

Type of visit: Case Management - Health Checks

On 03/01/2024 at 12:30 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator, Fathma Ansari and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 133.9 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked. Smoke detectors were in working condition. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 02/10/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. The Following deficiencies were observed: At 2:50pm during Facility tour LPA observed an unsecured sharps container with sharps in R2's closet At 2:52pm during facility tour LPA observed the hot water temperature at 133.9 degrees Fahrenheit. LPA also administered a Technical Assistance for the fire extinguisher being recently expired. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 2, 2024

(e) Water supplies ...maintained as follows: (2) Faucets used by residents for personal care ... shall deliver hot water. Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above by having the hot water temprature at 133.9 degrees Fthe state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: By POC date administrator agrees to adjust water temperature to meet regulations and self certify to CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(1) · Plan of correction due date: Mar 1, 2024

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in having unlocked sharps which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: Licensee removed sharps container during visit