Golden Legacy Elderly Care III

Type of visit: Required - 1 Year

On August 28, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Gloria Clarke-Daley and explained the purpose of today's visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility is licensed for six non-ambulatory residents. There are currently six residents who reside at this facility. The facility has an approved hospice waiver for one. The LPA Martinez toured the facility with Gloria Clarke-Daley on August 29, 2026, at 11:30 AM. LPA Martinez reviewed three out of three resident files, and the files were maintained. LPA Martinez reviewed three out three staff files. Three out of three staff files did not contain 2026, twenty hours annual training documentation. LPA Martinez spoke with the Licensee, and they confirmed 2026, annual training was not completed. Staff 1 (S1) last twenty hours annual training document was dated November 11, 2024. Staff 2 (S2) last twenty hours annual training document was dated March 20, 2025. Staff 3 (S3) last twenty hours annual training document was dated February 10, 2025. The facility has a infection control plan and an emergency disaster plan. LPA Martinez reviewed two medication administration records (MARs). The MARs were kept current. The facility is sanitary and furnished. Common areas and bedrooms are in good repair and furnished. The facility has an adequate food supply. The facility water temperature 75 degrees and water temperature measured at 105 degrees. The facility has a first aid kit, and the exterior gate is in good repair. The exterior patio is in good repair and furnished. The facility has a public phone. Fire extinguisher is in good repair. Based on this annual inspection, a deficiency was cited and can be found on the 809D page. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 28, 2026

Allegation investigated: The Administrator is not present at the facility for a sufficient amount of time.

Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived at the facility unannounced on July 02, 2026, at 9:30 AM to deliver complaint findings, LPAs met with Gloria Clarke-Daley and Diana Garcia, and explained the purpose of the visit. Throughout the course of the investigation, LPAs conducted interviews, facility inspections, and file reviews. During a file review, it was learned that resident files were not maintained. Required documents were not complete, and two reappraisals have not been completed. Additionally, the facility printer/copy machine is not in good repair, and facility staff member is not able to print out July 2026, Medication Administration Records (MAR). As of July 02, 2026-9:30 AM , the Administrator has not delivered MARs to the facility. In addition, the Administrator was not present at the following Community Care Licensing inspection visits: February 20, 2026, July 02, 2026, and July 30, 2025. report continued on LIC 9099-C. Substantiated As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 27-AS-20260211102526

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jul 16, 2026

87405(a) Administrator - Qualifications and Duties:...administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...This requirement was not met as evidence by: based on observation, interviews, and file reviews, the Licensee did not ensure that the admin was present at the facility a sufficient amount of hours to complete management/administration duties. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: The Administrator shall be present in the facility 40 hours per week starting July 02, 2026. LIC 500 Personnel report shall be emailed to LPA Martinez by July 17, 2026 by 5:00 PM. Licensee will appoint a new administrator by POC date July 17, 2026.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Avelina Martinez and Sulma Lopez arrived at this facility unannounced on July 02, 2026, at 10:11 AM to conduct a case management visit. LPAs met with Gloria Clarke-Daley and Diana Garcia and explained the purpose of the visit. The purpose of the visit today, is in response to the following learned deficiencies: Reappraisals, It was learned that R1 last Reappraisal/Needs and Service Plan was on May 13, 2025. Resident 6 (R6) last Reappraisal/Needs and Service Plan was on June 24, 2025. Resident 3's (R3) LIC 602 Medical Assessment for Residential Care Facilities for the Elderly (LIC602) is not complete. Section V. Licensed Medical Professional information is missing information. Resident 4 (R4) LIC 602 Medical Assessment for Residential Care Facilities for the Elderly (LIC602) is not complete. The document has multiple sections that are not completed. It was also learned that the facility printer is not in good repair. As a result, facility staff are not able to print out July 2026 medication administration records (MAR). There is no record for medication administration as of July 1, 2026. As of 9:30 AM today July 02, 2026, the Administrator has not provided MARs to the facility. The Licensee arrived at the facility approximately 12:37 PM. Continued... LPA Lopez conducted a medication audit and based on the audit findings, the facility did not have the following medications for Resident 3 (R3): diphenhydramine 25mg, Guaifenesin 100mg/15ml. Additionally, R3's prescription medication Senna 8.6mg was not included in the MAR entry. Resident 5 (R5) did not have the following medications in the facility: Chlorhexidine 0.12% Solution, and Docusate Sodium 250mg. It was learned that these medications ran out yesterday and refills were requested yesterday. This resulted in R5 missing their morning dosages. Resident 6's (R6) MAR did not reflect the following medications: Senna 8.6mg and Milk of Magnesia 400mg/5m. It was learned by S1 that the facility printer is in disrepair. Medication Administration Records (MAR) for the month of July have not been printed. As a result of this visit, the following deficiencies were cited, per Title 22 Regulations, Division 6. The deficiencies were cited on 809-Dthe state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jul 16, 2026

87463(a) Reappraisals: the pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition...This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure that a reappraisal was conducted for R1.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Facility staff agrees to complete reappraisal audits and complete outdated reappraisals by POC date 7/16/2026. Facility staff shall email completed reappraisals to LPA Martinez by POC date 7/16/2026 at 5PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(14) · Plan of correction due date: Jul 16, 2026

87506(14) Resident Records: Each resident’s record shall contain at least the following information: Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidence by: Based on interviews, observations, and file reviews, the Licensee did not ensure to have a current Centrally Stored medication record. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Facility staff agree to implement a plan to ensure facility staff have access to Centrally stored medication record. providing the facility with a printer that is in good repair by POC date, 07/16/2026. Facility staff agrees to email stored medication record plan and updated information on printer status by poc date 07/16/2026 by 5PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 16, 2026

87506(a) Resident Records- The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...This requirement was not met as evidenced by; based on observation, file reviews, and interviews, the licensee did not ensure that documents were current, maintained, and complete. This posed a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Facility staff agrees to conduct a resident file audit and ensure that all required documents are maintained, complete, and updated by POC date 7/16/2026. Facility staff agrees to email LPA Martinez audit documentation by POC date 7/16/2026 by 5PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(4) · Plan of correction due date: Jul 16, 2026

87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by based on interviews, file review, and observations, the licensee did not ensure that residents were administered their medications as needed. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Facility staff agrees to conduct a medication audit by a medical professional by POC date 7/16/2026. Audit documentation shall be emailed to LPA Martinez by POC date 7/16/2026 by 5PM.

Type of visit: Required - 1 Year

On 7/30/25 at 1:45pm Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Legacy Elder Care III for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Gloria Clarke-Daley and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 108 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management visit on 11/22/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with caregiver Gloria and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 11/21/2024 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Nov 22, 2024

Allegation investigated: Personal Rights: Staff yells at residents

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Golden Legacy Elderly Care III RCFE on 11/14/24 at 9:00am to inform the licensee of complaint allegations mentioned above and to deliver findings. During this investigation, LPA Gould interviewed two staff members and three residents (See confidential name list LIC-811 dated 11/14/24). one staff member denied the allegations, the other staff member interviewed provided statements that they have had conversations with identified staff member (S2) about speaking with residents in a kind and respectful manner. Based on the interviews and statements obtained during the investigation process, the allegation is substantiated. One of the three residents interviewed provided statements and audio recordings of the identified staff member cursing and making inappropriate comments to the resident. LPA also identified additional title 22 violations as part of this investigation. Report continued on LIC 9099-C Substantiated The audio recordings also revealed staff S2 made statements of knowing R1 had soiled themselves in the evening by the smell and did not assist resident R1 until the following morning where S2 can be heard cursing and making inappropriate comments to R1. S2 did not assist resident in a timely manner. LPA has identified the conduct of staff S2 as an immediate risk to residents in care and had them removed from the facility during the inspection and per licensee will not be returning to the facility. During the interviews with S2, they made false statements to LPA when denying the allegation as LPA has recordings if their statements to residents. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Physical Abuse are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 27-AS-20241113162728

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Nov 18, 2024

Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by statements on audio recordings obtained during the inspection where staff S2 verbally abused resident R1 wich poses an immediate health, safety and personal rights violation to the residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee terminated the staff member during today's inspection. Licensee agreed to conduct personal rights training for all staff members and provide documentation of completed training by Monday, 11/18/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Nov 15, 2024

Managed Incontinence: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. this requirement was not met as evidenced by audio recordings in which staff S2 is overheard making statements that she smelled R1 had soiled self the prior evening and did not assist resident until the following morning which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee will submit an incontincence care plan for all residents who need assistance with incontinence by Monday, 11/18/24.

Type of visit: Case Management - Deficiencies

On 11/14/24 at 1:00pm, Licensing Program Analyst (LPA) Kevin Gould conducted a case management deficiencies inspection to address deficiencies observed while conducting a complaint investigation. LPA met with Licensee, Diana Garcia to discuss the inspection. LPA observed the facility is not disposing of resident's used syringes in a manner consistent with title 22 regulations, LPA observed a overflowing syringe container and used syringes in an unlocked cabinet near the living room. LPA was made aware of an aggressive act by a resident against a staff member. LPA was informed the resident attacked a staff member (S1) in September 2024 and no report was provided to the department. The facility did not meet title 22 regulations for reporting requirements. LPA conducted file review for all residents and observed several residents diagnosed with dementia with identified behaviors of inappropriate behaviors, wandering and aggressiveness. LPA reviewed the current staff schedule and did not observe an overnight staff member available to meet residents needs. Per LPAs review of records and resident needs, LPA has determined the facility does require an awake and on duty overnight staff member. LPA has determined the number of violations and the nature of the violations have demonstrated the administrator has not completed the duties of an administrator and has not demonstrated the knowledge and ability to remain in compliance of title 22 regulations. Per California Code of Regulations, Title 22, the follow deficiencies are cited during todays inspection. A copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(a)(3)(B) · Plan of correction due date: Nov 15, 2024

Infection Control Requirements: A syringe and needle shall only be used once per injection on one resident and then properly disposed of in accordance with the California Code of Regulations, Title 8, Section 5193. this requirement was not met as evidenced by LPA observations of syringes disposed of in an unlocked cabinet some in an overflowing syringe container and other syringes just placed in the cabinet which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Facility will ensure all used syringes are disposed of appropriately and provide a written plan of correction indicating the steps facility will take on a daily basis to ensure syringe disposal is conducted appropriately to meet title 22 regulations.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Nov 15, 2024

Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by the number and serious nature of the violations identified during the inspection including personal rights, reporting requirements, staff's conduct inimical to the health safety and well-being of residents in care which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: LPA and licensee discussed the departments technical support program and provided statements they would accept referral and participate in TSP.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 15, 2024

Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by unreported incidents including a resident's agressive acts against staff and inapropraite actions by staff inluding verbal abuse wich poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: The facility will provide a written plan of corrections of the daily steps facility will take to ensure all incidents are reported to the department in a manner that meets title 22 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(4)(A) · Plan of correction due date: Nov 22, 2024

Care of Persons with Dementia: In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met as evidence by: LPA review of resident files and identified needs for night supervision and the staff schedule with no identified overnight staff which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee has agreed to provide documentation of advertisements for employment on multiple professional platforms such as indeed or linked in and additional social media outreach by the POC due date.

Type of visit: POC

On 7/9/24 at 3:00pm Licensing Program Analyst (LPA) Kevin Gould Conducted an unannounced Plan of Correction (POC) inspection to ensure previous deficiencies have been corrected and there are no current health and safety issues. LPA conducted the inspection and observed all medications made inaccessible to residents in care and cigarettes and lighters in the home used by residents are stored secured from residents with a diagnosis of dementia. POC clearance letters were generated and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 9, 2024

Type of visit: Required - 1 Year

On 6/28/24 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Legacy Elderly Care III (RCFE) for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Kimberly Sloan and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 117 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed medications, not centrally stored or secured from residents. LPA observed several medications and inhalers in common areas not secured from residents. Additionally, LPA observed unused needles stored in a unsecured cabinet along with the needle disposal container. LPA also observed a resident with dementia who retains their own lighter for smoking cigarettes. The facility is retaining cigarettes for resident but other residents also leave their cigarettes in common areas accessible to residents with dementia. Report Continued on LIC 9099-C LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 28, 2024