Facility Evaluation Report

On 05/07/2025 at 9:45 A.M., LPA Pamela Bunker conducted an unannounced Case Management visit. LPA Bunker met with Assistant Administrator Rodolfo Lozada and spoke to Licensee Angelique S. Gradney via telephone, and the purpose of the visit was explained. LPA was granted entry to the facility.

On 05/07/2025, the department investigated a Complaint Report, dated 01/31/2024, Control #11-AS-20240131103123, regarding the allegation that Resident #1 (R1) went to the hospital with serious wound issues: Stage 3, Stage 4, and unstageable wounds.

On 05/07/2025, Staff members reported that R1 was referred to Golden Care Living III from a facility that was closing. R1 was admitted to the facility on 10/14/2023 and was already receiving wound care treatment for pressure wounds at the time of admission from Legend Home Health, from 02/17/2023 - 01/25/2024, prior to being admitted to Golden Care Living Ill. Upon admission, the resident presented with a pre-existing decubitus ulcer in the buttocks and groin area. The nurse and primary care physician remained in constant communication throughout the resident's entire stay at the facility.

Licensee Angelique S. Gradney and Assistant Administrator Rodolfo Lozada confirmed that R1 was admitted with Stage 1 and Stage 2 wounds. On 01/25/2024, R1 was hospitalized at Torrance Memorial Medical Center under the care of Legend Home Health Care, Inc., due to worsening wound conditions, including Stage 3, Stage 4, and unstageable wounds. Although R1 was receiving Home Health Services, R1 was not in hospice at the time of admission.