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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320024
Report Date: 08/05/2025
Date Signed: 06/04/2026 09:48:50 PM

Document Has Been Signed on 06/04/2026 09:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN CARE LIVING IIIFACILITY NUMBER:
198320024
ADMINISTRATOR/
DIRECTOR:		GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1308 HICKORY AVETELEPHONE:
(310) 787-8369
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 5DATE:
08/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Rodolfo LozadaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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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.
See continued LIC809-C page 3
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2026 09:48 PM - It Cannot Be Edited


Created By: Pamela Bunker On 08/05/2025 at 08:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2025
Section Cited
CCR
87615(a)(1)

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87615 (a) Prohibited Health Conditions:
Persons who require health services for or have a health condition including, Stage 3 and 4 pressure injuries shall not be admitted or retained in a residential care facility for the elderly.
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The Licensee will review and train staff on Prohibited Health Condition and comply, and ensure that the facility will not admit or retain any residents with a health condition of Stage 3 or 4 pressure injuries.
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Resident 1 (R1) was receiving treatment from Legend Home Health Services for stage 3 and 4 unstageable pressure injuries. R1 was not on hospice at the time of admission.
The violation poses a potential health and safety risk to residents in care.
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The deficiency was corrected prior to today's visit.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Pamela Bunker
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 08/05/2025
NARRATIVE
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Continued LIC809-C page 2

According to the California Code of Regulations, Title 22, Division 6, Chapter 8. LPA observed the following deficiencies: The facility is being cited on the attached LIC809-D.

An exit interview was conducted, and appeal rights were issued and covered with the facility Assistant Administrator, Rodolfo Lozada.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
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