197609631-8-7-2024-31-AS-TAGD-D8HNSZ-20240826104359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 08/07/2024
Date Signed: 08/07/2024 01:56:46 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: 38	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Adriana Cisneros - Assistant Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff stole resident's credit card

Staff did not safeguard resident's funds.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit.

LPA conducted physical plant tour at 9:05 AM, requested copies of facility documents relevant to the investigation at 9:43 AM and interviewed staff and residents between 10:00 AM to 12:00 PM. LPA also conducted record review between 12:15 PM to 1:00 PM. Regarding the allegation that staff stole resident's credit card, it was alleged that staff is taking Resident #1 (R1)'s credit cards. LPA's interview with R1 on 01/25/24 at around 12:30 PM revealed that no staff took R1's credit card and R1 kept all of R1's bank cards and denied any usage from any staff. LPA's observation also revealed that R1 had own one on one caregiver from Lanterman Regional Center five (5) days a week during daytime. LPA's interview with the R1's caregiver confirmed that R1 did not lose any bank card or not that the caregiver was aware of since started working with R1. (continued on LIC 9099-C)

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: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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-20240123093103

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: GOLDEN HILLS RETIREMENT CTR INC	FACILITY NUMBER: 197609631
	VISIT DATE: 08/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 9099)

Regarding the allegation that Staff did not safeguard resident's funds, it was alleged that R1 had a $6000 check that was missing. LPA's interview with R1 on 01/25/24 at around 12:30 PM revealed the supposed missing check was from a settlement money from when R1 had a car accident about eight (8) or more years ago. Further interview also revealed that it supposed to have come from R1's lawyer that R1 could not remember. LPA's interview with the Administrator today at 11:10 AM revealed that R1 did not disclose anything financial to the facility since admission and the administrator was not aware of any accident happened to R1 while living at the facility nor the facility received any letter from any lawyer other than the regular lawyer of R1 who pays R1's rent. LPA's record review today between 12:15 PM to 1:00 PM revealed that R1 was able to manage own cash resources and LPA's interview with the administrator today at 11:10 AM confirmed that R1 had been managing own cash resource from the time R1 was initially admitted at this facility in 2013, so any mail or money goes directly to R1 and never passed on to or through the facility.

Based on the information gathered during this and prior visits, these allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2