197609631-4-4-2023-31-AS-NMAN-CRNS9Q-20230509134108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 04/04/2023
Date Signed: 04/04/2023 04:15:37 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
03/29/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230329080514

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:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Itzel Guevara - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility did not provide refund in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA initially met with staff Emily Shah, administrator Itzel Guevara arrived ten (10) minutes later. LPA explained the reason for the visit.

LPA conducted physical plant tour at 9:38 AM, requested copy of facility documents relevant to the investigation at 10:00 AM and interviewed staff between 10:00 AM to 11:30 AM. LPA also conducted records review between 11:30 AM to 12:30 PM. It was alleged that the facility withdrew payment for February and March 2023 for Resident #1 (R1) and not getting a refund for these months as R1 left on 01/14/23 to the hospital and never came back. LPA's record review between 11:30 AM and 12:30 PM revealed that R1 was self responsible and paid the facility by own personal check. LPA's interview with the administrator and staff today between 10:00 AM to 11:30 AM revealed that the facility has no access whatsoever to R1's bank account and/or money and pay by own personal check so it is not possible for the facility to withdraw money from R1's account unless R1 paid by own check but record shows that R1 only paid only up to the month of 01/2023 (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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-20230329080514

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: 04/04/2023

NARRATIVE

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(continued from LIC 9099)

Further, LPA was able to obtain a copy of the check issued by the facility refunding R1 for the entire month of January 2023. LPA was also able to obtain copy of the personal check issued by R1 paid to the facility and a copy of the text message sent to the Business Office Manager (BOM) by R1's family member informing the BOM that the family member received the refund check and the issue of refund are now resolved.

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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