197609631-5-16-2024-31-AS-RORN-D5HLMC-20240522085231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 05/16/2024
Date Signed: 05/16/2024 01:54:32 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
01/31/2023 and conducted by Evaluator Tuesday Cabiness

COMPLAINT CONTROL NUMBER: 31-AS-20230131105058

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:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Adriana Cisneros & Itzel Guevara		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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1. Staff took resident's personal items received by mail
2. Staff do not ensure that resident's dietary needs are met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to deliver the final finding of the allegations mentioned above. LPA met with Adriana Cisneros and Administrator Itzel Guevara and informed the reason of the visit.

Allegation # 1: It was alleged staff took resident’s personal items received by mail. On 02/09/2023, former LPA Shira Stamps, conducted the initial visit and interviewed staff and residents. During today’s visit, from 12pm to 2pm, LPA conducted additional interviews and obtained resident records. Through interviews, it was reported that residents receive their packages and mail, and never have had any issues. Residents also stated that they were not 100% sure staff opened or took their mail. Therefore, based on interviews, the allegation is Unsubstantiated at this time.

Allegation # 2: It was alleged staff do not ensure that resident’s dietary needs are met. On 02/09/2023, former LPA Shira Stamps, conducted the initial visit and interviewed staff and residents. During today’s visit,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (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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Control Number 31-AS-20230131105058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GOLDEN HILLS RETIREMENT CTR INC	FACILITY NUMBER: 197609631
	VISIT DATE: 05/16/2024

NARRATIVE

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LPA conducted additional interviews from staff and residents, and obtained and reviewed records pertaining to the complaint. From the information obtained, it was revealed, R1 has had no dietary restriction on record for the last four (4) years. LPAs' interview with R1 also revealed that R1 was aware that R1 had no dietary order from a physician. Therefore, based on documentation and interviews, the allegation is Unsubstantiated at this time.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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