315002894-6-1-2023-25-AS-KHOS-CSJP5F-20230606110038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002894
Report Date: 05/11/2023
Date Signed: 06/01/2023 11:11:18 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20230221102112

FACILITY NAME:	GOLDEN HILLS CARE HOME		FACILITY NUMBER:	315002894
ADMINISTRATOR:	MAHAJAN, VIVEK		FACILITY TYPE:	740
ADDRESS:	1434 ELM STREET		TELEPHONE:	(916) 474-4920
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS: 4	DATE:	05/11/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Vivek Mahajan, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff did not meet resident's incontinence care needs.

INVESTIGATION FINDINGS:

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*This document was AMENDED. Additional information has been obtained regarding the allegation of Facility staff did not report injury to resident's responsible person. And LIC9099 dated 06/01/23 addresses the updated findings to this complaint allegation.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Vivek Mahajan during today's inspection. LPA investigated allegation, "Facility staff did not meet resident's incontinence care needs." Relevant party stated the facility staff refused incontinence care to R1 on one occasion. R1 was unable to be interviewed. LPA interviewed a caregiver in which they stated they have never refused any care to R1.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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 25-AS-20230221102112

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN HILLS CARE HOME	FACILITY NUMBER: 315002894
	VISIT DATE: 05/11/2023

NARRATIVE

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Caregiver stated they provided incontinence care throughout the day and night, and anytime the resident requests. LPA interviewed administrator in which he stated he is unaware of a time that staff refused care to R1 or any other residents in care. LPA interviewed 2 residents in care in which they stated that staff are helpful and have not refused them care. Due to the information gathered, LPA finds allegation to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was provided to facility administrator.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

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