197609631-2-16-2024-31-AS-NGID-D3HSBH-20240319134358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 02/16/2024
Date Signed: 02/16/2024 03:08:08 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.RO, 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
02/07/2024 and conducted by Evaluator Leslie Ngo-Castaneda

COMPLAINT CONTROL NUMBER: 31-AS-20240207092211

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:	02/16/2024
		UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Adriana Cisneros- Manager		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff does not ensure facility is free of pest.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced visit to investigate the above allegation. LPA was greeted by the facility manager Adriana Cisneros. LPA explained the reason for the visit. At 9:45 AM LPA met with facility administrator Itzel Guevara.

Entrance interview conducted.

LPA conducted a physical plant tour at 9:31 AM, requested facility documents relevant to the investigation which include but not limited to maintenance records and contracts for the pest control company. LPA reviewed records between 9:52 AM and 11:18 AM. LPA interviewed 5 staff and 13 residents between 11:20 AM and 1:08 PM.

Conitnue to LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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-20240207092211

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN HILLS RETIREMENT CTR INC	FACILITY NUMBER: 197609631
	VISIT DATE: 02/16/2024

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

The complainant’s concern is that the facility staff does not ensure the facility is pest free. LPA conducted a physical plant tour and interviewed residents. At the time of inspection, LPA did not observe any pests in the facility. Twelve(12) out of thirty-eight (38) residents state that there were no pests observed in their rooms. LPA toured the room of the one resident who may have had an issue with pests, however, did not observe and active infestation.

Interviews with five (5) out of fourteen (14) staff) revealed that there are no pests observed in the facility. LPA reviewed the pest control company’s invoice. The facility maintains a contract with the pest control company to come out a couple time a month to ensure the facility is free of pests which include roaches.
Therefore, based on inspection, observation and interviews, there is an insufficient information to support the allegation.

The allegation is deemed Unsubstantiated at this time.

Exit interview.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2