197609631-7-2-2024-31-AS-TAGD-D92SVY-20240912141330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 07/02/2024
Date Signed: 07/02/2024 01:59:27 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
06/28/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240628155539

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:	07/02/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Itzel Guevarra - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident was physically abused while in care

INVESTIGATION FINDINGS:

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

LPA conducted physical plant tour at 9:22 AM, requested copy of facility documents relevant to the investigation at 9:53 AM, reviewed records between 10:00 AM to 11:30 AM and interviewed staff and residents between 11:35 AM to 1:00 PM. It was alleged that Resident#1 (R1) was slapped by a caregiver's husband and threw coffee at R1. No other information was provided for this allegation. LPA made a reasonable attempt to contact the reporting party to get more details of the allegation but to no avail. LPA's record review revealed that R1 was admitted at the facility on 07/20/23 and went to the hospital due to a medical condition on 11/27/23 and discharged to a Skilled Nursing Facility (SNF) on 12/01/23. LPA's interview with the assistant administrator today at 12:06 PM revealed that R1's sister took R1's belongings at the facility on 12/08/23 and told the facility that R1 was not coming back. (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: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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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Control Number 31-AS-20240628155539

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: 07/02/2024

NARRATIVE

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(continued from LIC 9099)

LPA's interview with Resident #2 (R2) and former roommate of R1 while still at the facility revealed that R2 did not remember R1 but did not witness any roommate being slapped or physically/verbally abused or being thrown coffee by any staff or anyone in their room. LPA's interview with the administrator today at 12:54 PM also revealed that she did not receive any complaint from R1 of being physically or verbally abused by anyone while still living at the facility.

Based on the information gathered during this visit, the allegation is 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: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC9099 (FAS) - (06/04)

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