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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197609631
Report Date:
07/18/2022
Date Signed:
07/18/2022 12:49:39 PM
Unsubstantiated
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
07/13/2022
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20220713095719
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:
07/18/2022
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Adriana Cisneros
TIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was able to wander from the facility while in care
Resident's hygiene and grooming needs not being met while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
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13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with facility staff and explained the reason for this visit.
LPA conducted a physical plant tour from 9-9:15am to ensure no immediate health and safety issues were present. LPA did not observe any immediate health and safety issues.
Resident was able to wander from the facility while in care
It is alleged that resident #1(R1) wandered away from the facility due to lack of care. LPA conducted an interview with facility staff from 9:15-9:45am regarding this allegation. LPA also conducted an interview with R1 regarding this allegation from 10-10:15am. LPA reviewed R1's facility file and obtained copies of pertinent information from 10:15-10:45am. Information obtained revealed that R1 left the facility on the morning of 7/11/22 at approximately 8am which R1 normally does. After R1 did not come back to the facility staff called 911 to report a missing person at approximately 8pm on the same day. Law enforcement came to the facility and made a report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/18/2022
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-20220713095719
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:
07/18/2022
NARRATIVE
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32
The next morning R1 was brought back to the facility by law enforcement. A review of R1's physician report and Needs and Appraisal show that R1 is able to leave the facility unassisted. Facility stated that they will have R1 reassessed to see if there is a change in condition. Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time.
Resident's hygiene and grooming needs not being met while in care
It is alleged that R1's hygiene and grooming needs are not being met. LPA conducted interviews with facility staff and R1 from 9:15-10:15am regarding this allegation. LPA reviewed R1's physician report and needs and service plan from 10:15-10:45am. Information obtained from interviews and record review show that R1 does not need assistance with hygiene and grooming. Facility has agreed for R1 to be reassessed to see if their care needs have changed. Based on the information obtained this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/18/2022
LIC9099
(FAS) - (06/04)
Page:
2
of
2