197609631-9-15-2022-31-AS-RRAZ-CK56CV-20221011204212

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:07:52 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
03/21/2022 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220321155906

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:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Adriana Cisneros		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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1.Staff physically abusing resident while in care
2.Staff verbally abusing resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness met with Facility Manager Adriana Cisneros and informed her the reason of the visit. LPA delivered the final findings to the allegations mentioned above:

Allegation # 1: Concerns were expressed that staff was physically abusing resident while in care. On 03/25/2022 and 09/15/2022, from various times, ranging from 930am to 2pm, LPA obtained facility/resident documents, and conducted interviews with the complainant, residents, and facility staff. According to the information obtained during the investigation, it was alleged that a staff was physically abusing resident # 1 (R1) while cleaning R1’s private area. LPA interviewed R1, who reported, there are times when staff could be rough when cleaning the private area, but staff are not physically abusing resident. Other residents reported to LPA, staff are not physically abusive. Therefore, based on interviews, the allegation is UNSUBSTANTIATED.

Allegation #2: Concerns were expressed that staff was verbally abusing resident while in care. On 03/25/2022 and 09/15/2022, from various times, ranging from 930am to 2pm, LPA obtained facility/resident documents,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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-20220321155906

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: 09/15/2022

NARRATIVE

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and conducted interviews with the complainant, residents, and facility staff. According to the information obtained during the investigation, it was alleged that a staff was verbally abusing resident # 1 (R1). LPA interviewed R1, who reported staff are not verbally abusive, and staff treat R1 well, and there are no issues. LPA interviewed other residents, who reported, staff treat them well and they are not abusive. Therefore, based on interviews, the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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