Complaint·May 22, 2026

S1 stated that they will come to work after Licensee has worked overnight and they observe that nothing has been done overnight. S1 stated that Licensee sleeps during their shift. S1 stated that they have arrived at the facility and resident (R2) will have a full blown diaper, in which they have sat in poop two (2) or three (3) times over. S1 stated that laundry and dishes are not done while Licensee works. S1 stated that they have observed food from the other night still out upon reporting to work. S1 stated that the dishwasher will be full and not started and the care home will have no clean dishes. S1 stated that Licensee does not check the resident rooms at night. S1 stated it is clear that Licensee sleeps throughout their shift. During visit conducted on February 18, 2026, LPA and Licensing Program Manager (LPM) Lauren Crocker toured the premises and conducted interviews, including R1, Licensee, and House Manager, Stephanie Harmon-Christensen. LPA and LPM also reviewed records for the residents. Interview with Licensee indicated that they did not document a pre-appraisal for R1. Interview with R1 indicated that the facility is understaffed and staffing is inadequate at the facility. R1 stated that only the Licensee works at night and they are concerned about their health. R1 stated that Licensee has muscle spasms and is unable to safely change and reposition R1 in bed. R1 stated that they have almost fallen off the bed while Licensee was attempting to change them. R1 stated that Licensee cannot put R1's diapers on correctly. R1 stated that they can observe that they smell like pee and haven't been cleaned or showered. R1 stated that they go pee every hour and pee twice per diaper change. R1 stated that the diapers being used by the facility are too small. R1 is using two (2) XL diapers but R1 stated that they need a size 5XL. As a result of the visit conducted on February 18, 2026, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1 Personal Rights of Residents in All Facilities (a) “Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” This requirement was not met based on interviews conducted and observations, which determined that the facility did not ensure to provide R1 with safe equipment to meet the resident's needs, including wearable diapers. Facility was required to obtain an adequate supply of 5XL diapers for resident in need. ** Report continued on 9099-C ** Interviews with S1 and House Manager indicated that Licensee would work NOC shift and sleep through their shift. House Manager stated that staff member (S3) would also sleep through their shift. Physician’s Report (LIC 602A) for R2 states R2 needs “total dependent assistance” for all activities of daily living (ADLs). Resident Appraisal for R2 on file states that R2 needs special observation/night supervision (due to confusion, forgetfulness, wandering) as they are “unable to get out of bed/supervision.” Appraisal/Needs and Services Plan for R2 dated December 18, 2025 states R2 “needs assistance with all activities and all ADL’S.” S1 stated that R2 has cut their arm from falling out of bed. S1 stated that R2 has fallen out of bed twice during Licensee's shift. S1 stated that S3 has left R2 on the floor because they couldn't get R2 up on their own. S1 stated that S3 gave R2 a blanket and pillow while they laid on the floor. S1 stated that the floors are hard. S1 stated that they did not know when R2 fell. S1 stated that resident (R3) has fallen and resident (R4) has fallen out of bed (LPA verified Incident Reports submitted regarding falls for both residents). S1 stated that all falls have been during Licensee's shift. S1 stated that R3's most recent fall was at approximately 7:15 AM ending in Licensee's shift. S1 stated that they lifted R3 into bed and called the paramedics. S1 stated that R3 bumped their head. S1 stated that House Manager told S1 to call paramedics. The Department received information from R2’s Home Health (HH) regarding R2’s fall. HH reported that R2 is mostly bedbound and is unable to turn or transfer self. HH reported to have visited R2 on January 3, 2026. HH reported that staff member (S2) stated that R2 had an unwitnessed fall and night shift caregiver (S3) left R2 on the floor for possibly one (1) to two (2) hours. HH reported that S2 had stated that S3 did not call supervisor until the end of their shift. HH reported that supervisor found R2 soaked in urine and blood to their right arm while face down on the floor next to their bed. HH reported that supervisor contacted paramedics and R2 was returned to bed and provided basic wound care. HH reported assessing R2’s arm and found no signs of infection. HH reported providing R2 wound care and instructing care staff regarding wound care as ordered by physician. HH reported providing extensive fall prevention education to care staff. HH recommended bed alarms and 24 hour closer supervision. ** Report continued on 9099-C ** HH reported a new rash that is possibly incontinence related with no open areas. HH reported both injuries to be deemed not serious injuries. PIN 25-06-ASC states the following: “to ensure resident safety, licensees as a best practice should immediately call 9-1-1 if a resident is experiencing any of the following symptoms/conditions listed below: (…) Falls with complaints of pain or loss of range of motion.” On February 20, 2026, the Department received a report from the Local Long Term Care Ombudsman authored by Sacramento Metro Fire Department. The report states the following: “On February 19 th at 1212am, Engine 32 and Medic 32 responded to Golden Moments Care Home for a person complaining of abdominal pain and stated there were no staff in the facility. Upon arrival, [medical personnel] was unable to find any staff at the care facility. [R1], a resident at the facility who weighs approximately 550 lbs was found holding onto [their] bed and table and about to fall to the floor. [R1] stated [they] had been yelling for help for approximately 2 hours with no staff responding. After 10 minutes, [S2], an employee entered through the front door and stated [they were] on [their] lunch break and had been gone for at least an hour. [S2] then went and retrieved Mr. Mark Graham, the facility owner, who was asleep in a back bedroom. [S2] initially stated [they] had permission to leave for [their] lunch, but Mr. Graham stated [they were] not aware [S2] had left. [R1] was subsequently left yelling for help for abdominal pain and clinging to [their] bed to prevent from falling to the floor for anywhere from one to two hours. [Medical personnel] informed Mr. Graham that [they] would be transporting [R1] to the ER for [their] medical complaint and requested any records including medical history and medications for [R1]. After 10 minutes, [Licensee] was unable to provide a single piece of information regarding [R1] including name, birthday, emergency contact, medical history, medications, etc.. [Medical personnel] asked [them] for a copy of an intake form, which [they were] unable to provide. [Medical personnel] advised Mr. Graham that [medical personnel] would be filling an APS report due to the abandonment of [R1] and failing to provide any information regarding a person in [their] care.” ** Report continued on 9099-C ** Interview with S2 conducted on February 19, 2026, indicated that they were working the previous night with Licensee. S2 stated that they texted Licensee that they would be leaving on their lunch break to get gas. S2 stated that Licensee did not respond to their text message prior to leaving the care home. S2 stated that, when they returned to the facility, they found the fire department at the care home taking R1. S2 stated that the fire department was mad and didn't tell S2 much. S2 stated that they told the fire department that Licensee was at the facility. S2 stated that Licensee was sleeping in a resident room and had to be woken up for the fire department. Interview with R1 conducted on February 27, 2026, indicated that they were yelling for two (2) hours for assistance before contacting the fire department. R1 stated that they didn’t believe that Licensee was on the premises. R1 stated that, if the house had been on fire, they would be dead. R1 stated that they had been experiencing stomach pain and was wanting Tylenol. R1 stated that they were also having difficulty breathing. R1 stated that they did not want to return to the care home. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D pages. Facility is closed. A copy of this report and appeal rights were provided to the Licensee via certified mail. Interviews conducted with staff and residents did not indicate any concerns regarding staff physically abusing residents in care at the care home. LPA did not observe any evidence of physical abuse from staff towards residents during the investigation. Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Facility is closed. A copy of this report was provided to the Licensee via certified mail.