Inspection Reports for
Golden Living Point Loma

During a complaint investigation, it was discovered that Staff #1 worked at the facility without fingerprint clearance and association. Staff #1 was removed from the schedule and terminated. A deficiency and civil penalty were issued.

The facility allowed Staff #1 to work prior to obtaining fingerprint clearance and association with the facility, which posed an immediate health and safety risk. Staff #1 was removed from the schedule and terminated. A deficiency was issued and a civil penalty assessed.

The complaint investigation was substantiated for neglect resulting in serious bodily injury, failure to assist with showering, and failure to address change in condition. The allegation that staff did not provide medication as prescribed was unsubstantiated. A $500 immediate civil penalty was assessed for the substantiated violations.

The investigation substantiated neglect of Resident #1 (R1), who suffered a serious infected wound leading to a below-knee amputation. The facility failed to provide shower assistance, observe and document changes in R1's condition, and provide adequate wound care. Another allegation regarding medication administration was unsubstantiated.

The visit was triggered by a complaint investigation that identified deficiencies related to Resident #1's documentation and medication orders. The deficiencies were substantiated and cited.

The facility failed to maintain current documentation for Resident #1, including an outdated Resident Appraisal and lack of a written physician order for an over-the-counter medication, posing potential health and safety risks.

The complaint investigation was substantiated for neglect/lack of supervision resulting in use of illegal drugs, with evidence including observations, photographs, resident and staff interviews confirming drug use inside the facility. The allegation of neglect/lack of supervision resulting in sale of illegal drugs was unsubstantiated due to insufficient evidence.

The investigation substantiated the allegation of neglect/lack of supervision related to illegal drug use by multiple residents inside the facility, including possession and use of methamphetamine and marijuana. The administrator failed to enforce policies effectively, did not report confiscated drugs to law enforcement, and no eviction actions were taken despite warnings. The allegation of neglect/lack of supervision resulting in sale of illegal drugs was unsubstantiated due to lack of evidence.

The visit was a follow-up to a substantiated case management investigation regarding the questionable death of a resident. The licensee was found culpable of negligence and cited for a Type A deficiency. A civil penalty was assessed and issued.

The Department determined that the facility was negligent in providing needed care and supervision to a resident with dementia, which led to the resident's fall and death. A civil penalty of $15,000 was issued for this violation.

The visit was a follow-up to a substantiated complaint investigation from May 20, 2022, regarding failure to provide needed medical care to a resident who fell and was in extreme pain but was not taken for medical evaluation. The complaint was substantiated.

The Department found that the facility neglected to provide emergent medical care after a resident's fall, resulting in a serious bodily injury (hip fracture) that required hospitalization and surgery. A civil penalty of $9,500 was issued for this violation.

A deficiency was cited for Staff #1 not being associated with the facility in the Licensing Information System despite working there, posing a potential health, safety, and personal rights risk to residents. An immediate civil penalty of $500 was assessed.

The complaint was substantiated. It involved a resident who left the facility unassisted and sustained a fall but no injuries. Staff were unaware the resident left as they were assisting other residents. The facility provides 24-hour supervision but was unable to monitor the front door after hours. The resident was relocated to a secured memory unit and a security system is planned to alert staff when doors are opened in the evening.

The investigation found that the facility did not ensure supervision for one resident who left the facility unassisted, posing a potential health and safety risk. The allegation was substantiated and the facility plans to install door alarms to prevent future incidents.

The complaint investigation was substantiated for the allegation that medications were not given as prescribed to Resident #1, including dispensing a medication causing an allergic reaction despite hospital documentation. The allegation of medication error resulting in injury was unsubstantiated.

The investigation substantiated that medications were not given as prescribed to Resident #1, posing an immediate health and safety risk. The facility continued dispensing a medication causing an allergic reaction despite hospital documentation. Another allegation of medication error resulting in injury was unsubstantiated due to lack of evidence linking the fall to medication.

The complaint was substantiated based on interviews, record reviews, and outside sources. The allegation that staff did not administer medications as prescribed was found valid. The resident's medical condition was negatively affected due to lack of medication.

The investigation substantiated that facility staff failed to administer prescribed medications to resident R1 for multiple days, posing a potential health risk. The facility had run out of Nortriptyline and did not timely order medication refills, resulting in medication omissions from January 29 to February 18, 2024.

The visit was triggered by a complaint, but the deficiencies cited were unrelated to the complaint allegations.

The licensee failed to ensure that an individual (Staff 1) working at the facility had a transferred criminal background clearance prior to working, posing an immediate safety risk to all 97 residents. A deficiency was cited regarding staff association and a civil penalty of $500 was issued.

The complaint investigation was substantiated for allegations that medications were not given as prescribed and that a resident had access to dangerous items. Other allegations including lack of supervision resulting in injury, failure to provide incontinent care, failure to assist or arrange medical care, and failure to safeguard personal items were unsubstantiated.

The investigation substantiated that medications were not given as prescribed to one resident and that one resident had access to items posing a danger. Other allegations related to lack of supervision, incontinent care, medical care assistance, and safeguarding personal items were unsubstantiated.

The complaint was substantiated based on interviews and record review. The facility admitted no telephone services were available after business hours. The administrator is working with Verizon to have phones operable 24 hours with voicemail monitored hourly.

The investigation found the allegation substantiated; the facility telephone was not operable at night after business hours, posing a potential safety risk to residents. The administrator confirmed ongoing efforts with Verizon to restore 24-hour telephone service with voicemail monitored hourly by staff.

The Licensing Program Analyst observed that not all independent residents had a secured area to store their medications, including controlled substances, posing a potential health risk to one resident out of 85 in care. A deficiency was cited related to medication storage.

The complaint investigation was substantiated for the allegation that the facility changed a resident's room accommodations without amending the admissions agreement. The allegation that the facility did not safeguard the resident's personal belongings was unsubstantiated.

The investigation substantiated that the facility changed a resident's room without proper notice or amending the admissions agreement, posing a personal rights risk. The allegation that the facility did not safeguard the resident's personal belongings was unsubstantiated due to insufficient evidence.

The complaint alleged the facility was retaining a resident requiring a higher level of care. The allegation was substantiated based on interviews, record reviews, and observations indicating the resident was unable to safely manage insulin injections and blood sugar checks without skilled professional assistance.

The investigation substantiated that Resident #1 requires a higher level of care due to inability to manage their diabetes medications and blood sugar checks independently. The facility lacks a skilled professional to assist with insulin injections, posing a potential health and safety risk.

The complaint investigation was substantiated for failure to provide prescribed medications and maintain a safe and sanitary environment for Resident #1. The allegations regarding diabetic diet provision and room temperature were unsubstantiated. Civil penalties were assessed for repeat violations within a 12-month period.

The investigation substantiated that the facility failed to provide Resident #1 with prescribed medications as required and did not maintain the resident's room in a clean, safe, and sanitary condition, posing immediate and potential health and safety risks. However, allegations regarding failure to provide a diabetic diet and maintain a comfortable room temperature were unsubstantiated.

A deficiency was observed and cited due to the facility not having current resident appraisals on file for 3 out of 86 residents, which poses a health and safety risk. The administrator acknowledged the oversight and plans to complete the reappraisals and submit proof of correction.

The complaint was substantiated. The allegations included failure to maintain hot water temperature and bathing facilities not being maintained in operating condition. The investigation confirmed these issues during the unannounced visit.

The investigation found that the hot water temperature in the shower of Room 41 was inconsistent, rising above the regulated 105-120 degrees F range, reaching up to 128 degrees F, posing a safety risk. Additionally, the shower knobs in Room 41 were faulty and did not operate correctly, preventing proper water flow control and shutoff.

The complaint investigation was substantiated. Allegations included staff neglect causing serious injury, medication errors, unexplained bruising, and failure to report incidents to the resident's authorized representative. The resident experienced multiple falls, was not sent for medical evaluation, and sustained a hip fracture. Medication was not administered as prescribed, and the responsible party was not notified.

The investigation substantiated the allegations that the facility failed to obtain medical treatment for a resident after multiple falls, did not administer prescribed medications timely, did not notify the resident's responsible party about falls, and failed to implement fall prevention measures. The resident sustained a hip fracture requiring surgery, and the facility was cited for multiple deficiencies.

The visit was triggered by a complaint investigation. Deficiencies were substantiated related to resident #1's care and medical records.

Deficiencies were found related to failure to provide basic services by allowing a resident to leave unassisted despite physician restrictions, and failure to have a current medical assessment within one year for a resident. These deficiencies posed health and safety risks to residents.

The facility failed to complete a current Resident Appraisal for one resident, with the last appraisal dated 11/29/2018. This deficiency was cited as it poses a potential health and safety risk to the resident in care.

The visit was complaint-related, following a self-reported incident where Resident #1 left the facility and was hospitalized. The complaint was substantiated by the finding of a missing current Resident Appraisal.

The facility failed to have a current Resident Appraisal on file for one resident, which posed a potential health and safety risk. A deficiency was cited related to this failure.

The visit was complaint-related due to a death report. The preponderance of evidence standard was met, and the licensee was found culpable of negligence resulting in the resident's death.

The investigation found that staff failed to update the resident's care plan after discharge from a skilled nursing facility, resulting in inadequate supervision and assistance. The resident fell twice on the day of the incident, ultimately sustaining a fatal traumatic brain injury. The licensee was found culpable of negligence.