Inspection·July 23, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that outbreaks of communicable disease are identified and reported to the California Department of Public Health (CDPH) and local public health officer, in accordance with the facility ' s policy and procedure on Communicable Diseases – Outbreak. The facility failed to report a Coronavirus 2019 (COVID- 19, an infectious disease) Outbreak in the facility, to the CDPH within 24 hours of occurrence for five (Residents 1, 2, 3, 4, and 5 of eight sampled residents who tested positive for COVID-19. The facility reported to the local health department on 7/16/2024 but did not notify the CDPH. Residents Affected - Few The facility ' s first resident with positive COVID 19 result was Resident 1, As a result, the California Department of Public Health was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare and safety of the residents and staff during this outbreak. Findings: A review of resident 1 ' s admission record indicated the resident was admitted on [DATE], with a diagnosis of, but not limited to Hemiplegia (cannot move muscles) and hemiparesis (weakness on one side of body) following cerebral infarction (an interruption in the flow of blood to cells in the brain). A review of Resident 1 ' s History and Physical dated 7/7/2024, indicated this resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Rapid antigen test for Covid 19 dated 1/15/2024, indicated a positive Covid 19 result. A review of Resident 2 ' s admission record indicated the resident was admitted on [DATE], with a diagnosis of, but not limited to Chronic obstructive pulmonary disease (common lung disease that causes airflow and breathing problems). A review of Residents 2 ' s history and physical dated 12/18/2023, indicated this resident does not have the capacity to understand and make decisions. A review of Resident 2 ' s Rapid antigen test for covid 19 dated 1/15/2024, indicated a positive Covid 19 result. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 056317 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)