197609631-5-22-2024-31-AS-TAGD-D92SG8-20240912135132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 05/22/2024
Date Signed: 05/22/2024 01:58:15 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
05/16/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240516145438

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:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Itzel Guevarra - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff threatened resident

Staff do not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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

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

LPA conducted physical plant tour at 9:18 AM, requested copies of facility documents relevant to the investigation at 10:24 AM and interviewed staff and residents between 11:00 AM and 1:00 PM, It was alleged that Resident #1 (R1) was threatened by a staff to throw R1 in the stairs in R1's wheelchair. LPA's interview with R1 today at 11:12 AM revealed that it wasn't a staff who threatened R1 but another resident of the facility. LPA's interview with Resident #2 (R2) who allegedly threatened R1 revealed that R2 did not know R1 and did not threaten anyone. Further interview with R1 also revealed that R1 was not threatened directly by R2 but only overheard it and did not remember when and where R1 overheard it.

(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: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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-20240516145438

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: 05/22/2024

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-C)

Regarding the allegation that Staff do not treat resident with dignity and respect, it was alleged that staff are calling R1 names. LPA's interview with five (5) residents or more than 10% of the current census today between 11:00 AM to 1:00 PM revealed that five (5) of five (5) residents believe that the staff are respectful and did not experience nor witness being called names by any staff of the facility. LPA's interview with Resident #3 (R3), R1's roommate for one and a half year (1 1/2) years revealed that R3 did not witness any staff calling R1 name when they were together in their room.

Based on the information gathered during this visit, the 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: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2