Golden Senior Assisted Living II

Allegation investigated: Facility staff retained a resident who requires a higher level of care. Staff did not address resident's change of condition. Staff did not prevent resident from developing a pressure injury. Staff are not meeting resident's medical needs.

On 07/24/26, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA spoke with Administrator Assistant Rudolfo “Ninyo” Lozada and the purpose of the visit was explained. Investigation consisted of the following: On 12/04/2025, LPA obtained Personnel Report (dated 10/16/25), Register of Residents (dated 10/25/25), R1 – R4’s Admission Agreement, Needs and Services Plan, Medication Administration Record (September 2025 – December 2025), Physician’s Report, and Incident Reports (date occurred 11/06/25 and 11/10/25). LPA interviewed Staff #1 – 3 and Residents #2 – 4. On 12/05/25, LPA received R1 – R4 Pre-appraisals, R1’s Cedars Sinai medical records (attestation signed 04/23/25), Los Angeles Community Hospital medical records (11/06/25 – 11/07/25, 11/12/25 - 11/13/25, Updated 11/21/25), Communication Responses, and Quality Home Health inquiry. Note: Resident #1 was not at the facility. Continue to LIC9099-C. Unsubstantiated Investigation revealed the following: Allegation: Facility staff retained a resident who requires a higher level of care. Regarding the allegation, “Facility staff retained a resident who requires a higher level of care,” it is alleged that staff does not have the ability to provide care and supervision appropriate to meet the needs of the residents. Record review revealed the following: R1’s Cedars-Sinai medical record (04/23/25) revealed R1 was at the hospital due to End-Stage Renal Disease (kidney failure). Admission Agreement revealed R1 was admitted into the facility on 07/03/25. Review of R1’s Physician’s Report (07/03/25) revealed R1’s secondary diagnosis as End-Stage Renal Disease, physical health status is good, weighed 132 pounds, and is able to feed self. Interviews revealed the following: three out of three staff interviews (S1 – S3) did not agree with the allegation. All three staff members indicated R1 receives dialysis services. S2 indicated R1 would vomit after dialysis and R1’s dialysis provider confirmed it was normal. S3 indicated R1 ate good but would vomit when full. S3 indicated R1 did not lose weight. Three out of three resident interviews indicated they do not require a higher level of care. R3 indicated a nurse visits to provide additional care services. R2 and R4 do not require additional care services and staff provide assistance with activities of daily living. Regarding the allegation, “Facility staff retained a resident who requires a higher level of care.,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Staff did not address resident's change of condition. Regarding the allegation, “Staff did not address resident's change of condition,” it is alleged, staff did not address changes in Residents appetite. Record review of R1’s Physician’s Report (07/03/25) revealed R1 weighed 132 pounds, is not on a special diet, and is able to feed self. Review of Los Angeles Community Hospital medical records (11/10/25) revealed R1 weighed (49 kg) 108 pounds, is underweight (BMI 16.9), and has severe protein-calorie malnutrition (BMI 16.9, poor intake, MST 3). Two out of two staff interviews (S2 – S3) indicated R1 ate good but vomited at times. S2 indicated that R1 has vomited after dialysis but the dialysis staff said it was normal. S1 indicated that R1’s health has not changed but R1 is agitated while at dialysis. S1 was instructed to call R1’s doctor but R1’s doctor said R1 was not on the list. R3 indicated staff will let the nurse know when they are not feeling well. Continue to LIC9099-C. Regarding the allegation, “Staff did not address resident's change of condition,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Staff did not prevent resident from developing a pressure injury. It is being alleged that staff does not move or adjust Resident #1. Record review of R1’s Physician’s Report (07/03/25) revealed R1’s primary diagnosis necrotizing fasciitis, uses a wheelchair, and does not require continuous bed care. Record review of email correspondence (10/08/25-10/09/25) revealed S1 seeking home health or wound care services for R1. S1 indicated noticing redness on R1’s skin and would like a nurse to assess and provide preventative assistance. Review of Los Angeles Community Hospital (11/06/25) revealed R1 has a skin rash in sacral area and the plan was to consult a wound specialist. Review of Harbor UCLA Hospital Record (11/10/25) revealed R1 did not have rashes or lesions. Review of Los Angeles Community Hospital (11/13/25; updated 11/21/25) revealed R1 had a stage two pressure ulcer of sacral region. S2 indicated that upon admissions, R1 had a sore on R1’s back. It was cleaned, bandaged, and no longer there. S3 indicated upon admission, R1 had a rash. Interview with S2 – S3 indicated that R1 is repositioned every two – two ½ hours. S1 indicated R1 was bedbound around the last week of October. R1 could sit in a wheelchair but was always in bed. R1 could move left to right but was very tired from dialysis (three times per week). S1 indicated S1 looked for home health services for R1 but there was an issue with insurance. R1 was discharged from the facility on 11/16/25. R3 indicated R3 is able to reposition self. LPA observed R2 and R4 to be ambulatory. Regarding the allegation, “Staff did not prevent resident from developing a pressure injury,” based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Continue to LIC9099-C. Allegation: Staff are not meeting resident's medical needs. Regarding the allegation, “Staff are not meeting resident's medical needs,” it is being alleged that staff does not have equipment to check Resident #1’s blood sugar level, does not schedule doctor appointments, nor retrieve medication. Record review of Cedars Sinai (attestation signed 04/23/25) does not diagnosis R1 with diabetes. R1’s Physician’s Report (07/03/25) does not include a diabetes diagnosis nor does R1 have a special diet. It revealed R1 took medication for: antidepressant and smoking cessation, epilepsy, GERD, hypotension, schizophrenia, and anxiety. R1 also took vitamins. Medication Administration Record (September 2025 – November 2025)) revealed staff retrieved R1’s medication for: antidepressant and smoking cessation, epilepsy, GERD, hypotension, schizophrenia, and anxiety. Though R1 ran out of antidepressant and smoking cessation aid on 10/10/25 – 10/21/25. R1 ran out of GERD medication on 10/15/25 – 10/21/25. R1 ran out of anxiety and depression medication on 10/15/25 – 10/21/25. R1 ran out of schizophrenia medication on 10/11/25 – 10/21/25. Screenshot (10/21/25) revealed R1’s medication was delivered to the facility. Review of Los Angeles Community Hospital (11/06/25) revealed R1 is check A1c at bedtime with regular insulin sliding scale low-dose. Review of Los Angeles Community Hospital (11/13/25) revealed R1 was transferred from Harbor UCLA Hospital for further management of symptomatic hypoglycemia. According to the transferring facility, the patient was found to have low blood glucose levels, associated with altered mental status and generalized weakness. Interview with S1 indicated R1 is not a diabetic so staff did not check R1’s blood sugar but blood pressure. S1 attempted to schedule doctor appointments but R1 had insurance issues. S1 indicated R1 had insurance problems and it didn’t cover the medication and the only option was to send R1 to the hospital to retrieve medication. The facility staff sent R1 to Torrance Memorial Hospital on 10/10/25 and R1 stayed there for about seven days. In addition, S1 indicated R1 would refused some medication after dialysis. S3 indicated S3 did not check R1’s blood sugar. R3 indicated R3 is able to do own injections, has enough supplies, and goes to Veterans Affairs for doctor appointments. R4 indicated family assists with medical appointments and transportation. R2 does not currently have a doctor and is new to the facility. Regarding the allegation, “Staff are not meeting resident's medical needs,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was emailed to the Assistant Administrator due to technical difficulties.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 11-AS-20251125145553

Type of visit: Required - 1 Year

On 01/29/2026, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Angelique Gradney. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory of which (5) may be non-ambulatory and (1) bedridden elderly resident ages 60 and above. The facility is approved for six (6) hospice waiver. Currently, there is one(1) hospice resident. The facility is a two-story structure located in a residential neighborhood. It consists of the following: five (5) residents' rooms, three (2) bathrooms, (4) staff rooms (1) staff bathroom, a living area, a dining area, a kitchen, a laundry room, a linen storage, an outside patio area, a garage used for storage. The second floor is mainly used for staff bedrooms. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 106.0 degrees F. A comfortable temperature was maintained in the facility 73 degrees F. LPA observed the facility is furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. Evaluation Report Continues on LIC 809-C The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. An audit of residents #1-#5 (R1-R5) service records and staff #1-#5 (S1-S5) personnel records. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Angelique Gradney #7001511740 Exp. 05/31/27. During the inspection visit, LPA observed the facility is in the process of renovation of the interior spaces which includes residents bedrooms and common living space areas. New furniture pieces are in boxes and will need to be reassemble. LPA observed old furnishings readily available in stored for purging. LPA observed all (CCL) mandated posters were not posted was due to the makeover process. Due to the renovation in process, a Case Management visit is required to follow up to ensure the facility is operating within Title 22 Regulations. No Deficiencies cited during this visit. An exit interview conducted with Angelique Gradney and a copy of the report is provided to Administrator Angelique Gradney.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Required - 1 Year

On 11/02/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Angelique Grandney. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory of which (4) may be non-ambulatory and (1) bedridden elderly resident ages 60 and above. The facility is approved for six (6) hospice waiver. Currently, there is one(1) hospice resident. The facility is a two-story structure located in a residential neighborhood. It consists of the following: five (5) residents' rooms, three (2) bathrooms, (4) staff rooms (1) staff bathroom, a living area, a dining area, a kitchen, a laundry room, a linen storage, an outside patio area, a garage used for storage. The second floor is mainly used for staff bedrooms. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 106.0 degrees F. A comfortable temperature was maintained in the facility 73 degrees F. LPA observed the facility is furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurate. Evaluation Report Continues on LIC 809-C During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. An audit of residents #1-#3 (R1-R3) service records and staff #1-#5 (S1-S5) personnel records. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Angelique Grandney #6005633750 Exp. 05/31/25 During the inspection visit, LPA observed the facility is in the process of renovation of the interior spaces which includes residents bedrooms and common living space areas. New furniture pieces are in boxes and will need to be reassemble. LPA observed old furnishings readily available in stored for purging. LPA observed all (CCL) mandated posters were not posted was due to the makeover process. Due to the renovation in process, a Case Management visit is required to follow up to ensure the facility is operating within Title 22 Regulations. Technical Violations and Advisory Notes were provided (see LIC 9102) No Deficiencies cited during this visit. An exit interview conducted with Angelique Grandney and a copy of the report is provided.the state’s words, verbatim · CDSS document, Nov 2, 2024

Type of visit: Collateral

On 06/19/24 at 10:01, Licensing Program Analyst (LPA) Ernand Dabuet initiated a Collateral visit at this facility. LPA met with caregiver Dinna Meniola. LPA explained the purpose of this visit is to gather information regarding a current complaint about Santa Fe Care Homes Complaint number 11-AS-20240617085500. The visit consisted of an interview with Dinna Meniola staff #1-#2 (S1-S2) who responsible for care and supervision for resident #1 (R1). Interviews with resident #1-#2 (R1-R2). Details on the interview are documented on LIC 812 crossed reference with Santa Fe Care Home #198205144. During the visit, LPA requested a copies of (R1's) service records and staff and resident roster for review. An exit interview was conducted with Angelique Gradney, and a hard copy was provided via email.the state’s words, verbatim · CDSS document, Jun 19, 2024