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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197607284
Report Date:
12/21/2021
Date Signed:
12/21/2021 03:40:25 PM
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
12/20/2021
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20211220132921
FACILITY NAME:
LIFESTYLE HOME CARE FOR SENIORS
FACILITY NUMBER:
197607284
ADMINISTRATOR:
BIENVENIDA B. GOUDEAUX
FACILITY TYPE:
740
ADDRESS:
11734 DORAL AVENUE
TELEPHONE:
(818) 368-5108
CITY:
NORTHRIDGE
STATE:
CA
ZIP CODE:
91326
CAPACITY:
4
CENSUS:
2
DATE:
12/21/2021
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Bienvenida Goudeaux
TIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not ensuring that the right care is being given to the resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit.
Regarding the allegation above it is alleged that the facility is not ensuring that the right care is being provided to resident # 1 (R1). LPA conducted interviews with the administrator and R1 from 1:30-2:30pm. LPA reviewed R1's facility file and obtained copies of pertinent information from 2:30-3:00pm.LPA also interviewed R1's physician with regards to the care R1 has received. Information from interviews revealed that there was no issue with the care that R1 receives from the facility at this time. There is concern that R1's responsible party who doesn't live in state and has not seen R1 in more than five years and there is concern that R1 is not involved enough to assist R1 in making decisions that R1 may not be capable of making themself. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. The issue was with R1's responsible person and not the facility and R1 receiving appropriate care at this time. Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/21/2021
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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