197609631-7-8-2021-31-AS-EMIR-C5UUYC-20210813155941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 07/08/2021
Date Signed: 07/08/2021 03:41:03 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
12/31/2020 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20201231160550

FACILITY NAME:	GOLDEN HILLS RETIREMENT CTR INC		FACILITY NUMBER:	197609631
ADMINISTRATOR:	GUEVARA, ITZEL		FACILITY TYPE:	740
ADDRESS:	10159 HILLHAVEN AVE		TELEPHONE:	(818) 352-1559
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	60	CENSUS: 36	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Itzel Guevara		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Financial Abuse

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegation.

As part of this investigation LPA interviewed the faciilty administrator and requested relevant facility records on 1/7/21, and on 7/8/21 LPA visited the facility to interview the administrator, Resident 1 (R1), and review additional records. LPA also interviewed the Frank D. Lanterman Regional Center representative for R1 telephonically.

Allegation #1, that the facility is committing "financial abuse" has been unsubstantiated based on the interviews conducted. At 12:00 PM LPA interviewed R1 and was informed that former staff member 1 (S1) had been soliciting money from them under false pretenses, and this began after S1 was no longer employed by the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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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Control Number 31-AS-20201231160550

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: GOLDEN HILLS RETIREMENT CTR INC	FACILITY NUMBER: 197609631
	VISIT DATE: 07/08/2021

NARRATIVE

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R1 stated that a sum of $14,000 had ultimately been returned to them by S1, but did not want to provide any financial documentation or proof to LPA. At 12:22PM LPA spoke with the caseworker for R1 and was informed that R1 is their own payee and neither the facility nor Regional Center are involved in their finances. Casworker confirmed that this issue was first reported to him, and likely began, after S1 stopped working at the facility. The allegation is unsubstantiated.

Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

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