Golden Hill Post Acute

In the surveyor’s words

From the most serious findings on record at Golden Hill Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to implement new, effective fall preventative measures after each fall incident for two of five residents reviewed for falls (Residents 1 and 2). These failures resulted in Resident 1 falling 13 times, sustaining two broken bones in her face and a broken rib.Findings:1. A review of Resident 1's undated Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) and Parkinson's Disease (a movement disorder of the nervous system that worsens over time). […]

• No harm, potential for more than minimal, patternF550Feb 19, 2026

  Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three of three residents (Residents 2, 3 and 4) who filed complaints with the California Department of Public Health (CDPH, an agency responsible for regulatory compliance of healthcare facilities).This failure had the potential to negatively affect the overall health and mental wellbeing of the residents.Findings:Three consumer complaints were filed with CDPH regarding the facility's failure to answer call lights in a timely manner. An onsite investigation was conducted. An interview was conducted on 2/12/26 at 5:15 P.M. with Resident 2. […]

• No harm, potential for more than minimal, patternF755Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to provide pharmacy services in accordance with accepted standards of practice when:1. A medication was not in stock for one of five sampled residents (Resident 5) when it was due. This failure had the potential for Resident 5 not to benefit from the full therapeutic effect of her medication. 2. Random controlled medication (medications with a high abuse potential) use audit for four out of eight sampled residents (Residents 6, 9, 37, 73) did not reconcile. The residents' medications were signed out of the controlled drug record (CDR, count sheet), but not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. […]

• No harm, potential for more than minimal, patternF838Jun 2, 2023

  Based on interview and record review, the facility failed to ensure a minimum of 3.5 direct care service hours and 2.4 certified nurse assistant hours per patient day (PPD), based on the care required by the resident population and care needs. This failure decreased the facility's potential to provide necessary care to residents. Findings: On 5/2/23 at 11:45 A.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated .Sometimes have fallen below the hours because of sick calls . but have hired more staff. The ADON stated, the facility had been projecting to be above the 3.5 for staffing. The ADON stated he covers as charge nurse if needed. […]

• No harm, potential for more than minimal, patternF812Oct 21, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare and distribute food in a sanitary manner when: 1. Foods were not labeled and dated in the walk-in cooler, 2. A juice dispenser was not sanitized, 3. A damaged spatula was used during food preparation, 4. Racks with compromised surfaces were used for holding sanitized dishes, and, 5. Coffee mugs and bowls appeared to have a white residue on the inside surface. These failures may result in risk for foodborne illness, as well as bacterial, chemical and foreign object contamination to the residents. Findings: 1. On 10/18/21 at 7:53 A.M., a kitchen tour was conducted with the Dietary Services Supervisor (DSS). […]