197609631-1-25-2024-31-AS-TAGD-D8HNT2-20240826104401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:47:50 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
01/23/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240123093103

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: 37	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Itzel Guevarra - Administrator		TIME COMPLETED:	02:47 PM

ALLEGATION(S):

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Staff are not following resident's dietary plan

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with administrator Itzel Guevarra and explained the reason for the visit.

LPAs conducted physical plant tour at 11:35 AM, requested copies of facility documents relevant to the investigation at 12:02 PM and interviewed staff and resident between 12:20 PM to 1:45 PM. Regarding the allegation that Staff are not following resident's dietary plan, it was alleged that staff are ignoring Resident #1 (R1)'s dietary restriction is being ignored by the staff. LPAs' record review at 12:15 PM revealed R1 had no dietary restriction on record for the last four (4) years. LPAs' interview with R1 also revealed that R1 was aware that R1 had no dietary order from a physician. Based on the information gathered during this visit. The allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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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