Golden Haven Care Center: Care Plan Failure - CA
That is what a December 2025 complaint inspection found at the facility on the 29th.
The device in question was a Hoyer lift, a floor-based mechanical sling system used to move residents who cannot bear their own weight. The lifts require trained operators. A transfer gone wrong can drop a resident, cause fractures, or worse. The family member who operated it was not staff.
The Director of Nursing acknowledged to inspectors that no care plan had ever been initiated for the resident to address the Hoyer lift at all. Not who should operate it. Not whether it should be stored inside the resident's room, which it was. Nothing.
That last detail matters. The lift was kept in the resident's room, accessible, available, sitting there as an invitation. No notation in the resident's care plan said otherwise.
Care plans at nursing facilities are not paperwork for their own sake. They are the document that tells every person who walks into a resident's room, including family, what that resident needs and how it should be provided. When a care plan is silent on something, the silence is its own kind of answer. It tells a family member, implicitly, that there are no particular instructions here. Handle it as you see fit.
The Director of Nursing did not dispute the finding. The care plan had not been initiated. The interdisciplinary team had not reviewed it to address this. A licensed nurse had not updated it. The facility's own policy, dated June 12, 2025, required exactly those things. The policy described a process where the interdisciplinary team and licensed nurses develop, finalize, and update care plans based on individual assessed needs, including changes in behavior and care. The policy existed. The process did not happen.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's language, not a judgment that the situation was trivial. A Hoyer lift operated incorrectly by someone without training is a mechanism for serious injury. The resident in this case was not reported to have been hurt. That is not the same as saying nothing dangerous occurred.
What the inspection does not say is worth naming clearly. It does not say the family member acted with bad intentions. Families in nursing homes often step in. They visit, they help, they want to feel useful, they want their loved one moved to the window or repositioned in a chair. When a piece of equipment is sitting in the room and no one has told them not to touch it, some of them will touch it. That is not a defense of what happened. It is an explanation of how facilities create the conditions for it.
Golden Haven's own policy gave the interdisciplinary team the tools to prevent exactly this. The policy described a living document, updated as needed, responsive to new problems, reviewed when circumstances changed. Somewhere between that policy and this resident's room, the process stopped.
The Director of Nursing's statement to inspectors was brief. The care plan had not been initiated to indicate that the Hoyer lift should not be stored inside the resident's room. That was the admission. No elaboration about why. No timeline for when it would be corrected. The inspection report does not record one.
The resident's family raised the concern themselves. They told the facility. That is how the complaint originated. A family member was doing something that the facility had never addressed in writing, and someone, perhaps another family member or the same one on reflection, flagged it as a safety problem. The facility then confirmed to inspectors that yes, there was no care plan, and yes, there should have been one.
That sequence, family raises alarm, facility confirms the gap, inspectors document it, is not how this is supposed to work. The gap was supposed to be caught before a family member was alone in a room with a mechanical lift and a resident who needed to be moved.
The inspection covered a single complaint. The finding was one deficiency. The harm level was classified at the lower end of the scale. None of that changes what the image is: a Hoyer lift stored in a resident's room, no instructions written anywhere about it, and a family member deciding on their own how to use it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Haven Care Center from 2025-12-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 21, 2026 · Our methodology
GOLDEN HAVEN CARE CENTER in GLENDALE, CA was cited for violations during a health inspection on December 29, 2025.
That is what a December 2025 complaint inspection found at the facility on the 29th.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.