191240840-9-20-2023-31-AS-MVAO-D2QSJJ-20240223125513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191240840
Report Date: 09/20/2023
Date Signed: 09/20/2023 06:01:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/14/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230914105456

FACILITY NAME:	GOLTZ ADULT HOME		FACILITY NUMBER:	191240840
ADMINISTRATOR:	CLIFTON VON BUCK		FACILITY TYPE:	735
ADDRESS:	1009 WEST AVE H-4		TELEPHONE:	(661) 433-9632
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	6	CENSUS: 4	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Clifton Von Buck, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident is being psychologically and physically abused by staff

INVESTIGATION FINDINGS:

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At 11:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Reuel Tumaliuan, Staff #1, who granted access to the facility. S1 called the Administrator Clifton Von Buck and LPA explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 11:10am, LPA requested resident and staff roster. At 11:20am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan/IPP, etc., relevant to the investigation. At approximately 11:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 11:45am – 2:40pm, LPA interviewed the Administrator, two (2) staff and four (4) clients.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230914105456

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLTZ ADULT HOME	FACILITY NUMBER: 191240840
	VISIT DATE: 09/20/2023

NARRATIVE

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Regarding allegation of “Resident is being psychologically and physically abused by staff”, LPA conducted interviews with the Administrator, two (2) staff members and four (4) clients. Staff interviewed denied psychologically and or physically abusing C1 or any other facility clients. Staff also denied observing or being aware of any other staff psychologically/physically abusing C1 or any other clients. In addition, LPA was able to interview all clients regarding this allegation. Three (3) out of four (4) clients interviewed informed LPA that the facility staff takes very good care of them and treats everyone with respect. All three (3) clients denied ever witnessing staff members psychologically and or physically abusing C1 or any other facility clients.

Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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