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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 05/16/2024
Date Signed: 05/16/2024 01:52:34 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
01/30/2023 and conducted by Evaluator Tuesday Cabiness
COMPLAINT CONTROL NUMBER: 31-AS-20230130162534
FACILITY NAME:GOLDEN HILLS RETIREMENT CTR INCFACILITY NUMBER:
197609631
ADMINISTRATOR:GUEVARA, ITZELFACILITY TYPE:
740
ADDRESS:10159 HILLHAVEN AVETELEPHONE:
(818) 352-1559
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:60CENSUS: 38DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Adriana Cisneros & Itzel GuevaraTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained fracture while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to to deliver the final finding of the allegation mentioned above. LPA met with Adriana Ciscernos and Administrator Itzel Guevarra and informed the reason of the visit.

It was alleged resident sustained fracture while in care. On 02/09/2023, former LPA Shira Stamps, conducted the initial visit, and interviewed staff and residents. During today’s visit, from 930am to 12pm, LPA conducted additional interviews and obtained resident records. From all the information obtained, it was revealed, resident # 1 (R1) complained to the in-house physician about pain in the shoulder. R1 did not inform staff that R1 was in any pain or injured. R1 was sent to the hospital by the orders of the doctor. It was later reported to the Administrator that R1 needed a higher level of care and would not be returning to the facility and would be admitted to a skilled nursing facility (SNF). It was also revealed to LPA, that staff visited R1 while in the SNF, and R1 never mentioned falling at the facility, and interviews revealed no-one witnessed R1 falling. Therefore, based on interviews, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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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