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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191240840
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:51:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20230720152356
FACILITY NAME:GOLTZ ADULT HOMEFACILITY NUMBER:
191240840
ADMINISTRATOR:CLIFTON VON BUCKFACILITY TYPE:
735
ADDRESS:1009 WEST AVE H-4TELEPHONE:
(661) 433-9632
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 4DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Ruel Tumaliwan - StaffTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff do not ensure that resident's diapering needs are being met while in care.

Staff do not ensure that resident's bathing needs are being met while in care.

Staff do not ensure that resident's clothing needs are being met while in care.

Staff do not ensure that resident's hygiene needs are being met while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA initially met with staff Ruel Tumaliwan who called the administrator Clifton Von Buck and explained the reason for the visit. Mr. Von Buck designated Mr. Tumaliwan to sign the report.

LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents relevant to the investigation. Between 10:34 AM to 12:20 PM, LPA conducted interviews with staff and resident and between 12:20 PM to 1:38 PM, LPA reviewed records. Regarding the allegation that Staff do not ensure that resident's diapering needs are being met while in care, it was alleged that Resident #1 (R1) needed help putting diaper due to bed wetting problems. LPA's record review today between 12:20 PM and 1:38 PM revealed that R1 was able to self care including but not limited to toileting, bathing, dressing, grooming and did not need any assistance. Further review also revealed that R1 does not require supervision in any settings. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20230720152356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLTZ ADULT HOME
FACILITY NUMBER: 191240840
VISIT DATE: 07/27/2023
NARRATIVE
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(continued from LIC 9099)

Regarding the allegation that Staff do not ensure that resident's bathing needs are being met while in care, it was alleged that R1 arrived from the home to program dirty and smelling. LPA's record review today between 12:20 PM and 1:38 PM revealed that R1 was able to self care including but not limited to toileting, bathing, dressing, grooming and did not need any assistance. Further review also revealed that R1 does not require supervision in any settings. LPA's interview with staff today between 10:34 AM to 12:20 PM revealed that R1 showered on R1's own daily as part of R1's routine before going to and after arriving from Day Program. LPA's interview with Resident #2 (R2) also confirmed that R1 shower on R1's own.

Regarding the allegation that Staff do not ensure that resident's clothing needs are being met while in care, it was alleged that R1 was wearing the same clothes multiple times. LPA's record review today between 12:20 PM and 1:38 PM revealed that R1 was able to self care including but not limited to toileting, bathing, dressing, grooming and did not need any assistance. Further review also revealed that R1 does not require supervision in any settings. LPA's observation today revealed that R1 had multiple clothes that is the same in style and color on R1's closet. LPA's interview with staff today between 10:34 AM to 12:20 PM revealed that R1 whatever clothes R1 want to wear every day.

Regarding the allegation that Staff do not ensure that resident's hygiene needs are being met while in care, it was alleged that there was an occasion wherein R1 had fecal matter on R1's pants. LPA's record review today between 12:20 PM and 1:38 PM revealed that R1 was able to self care including but not limited to toileting, bathing, dressing, grooming and did not need any assistance. Further review also revealed that R1 does not require supervision in any settings. LPA's interview with staff today between 10:34 AM to 12:20 PM revealed that both staff did not see R1 having fecal matter on R1's pants at any time and only noticed if R1 had a diarrhea on R1's underwear and other clothing when they do the laundry in the morning.

Based on the information gathered during this visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2