Golden Hills Retirement Ctr Inc

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff hit resident

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint to further investigate the above allegations. LPA initially met with staff Emily Shah who called the Administrator and explained the reason for the visit. LPA conducted physical plant tour at 12:30 PM, requested copy of facility documents relevant to the investigation at 12:50 PM and interviewed staff and resident between 12:50 PM to 1:30 PM. Regarding the allegation that Staff hit resident, it was alleged that Staff #1 (S1) and Staff #2 (S2) were "whacking" and "smashing" Resident #1 (R1)'s hands repeatedly. LPA's interview with S1 on 09/25/25 revealed that S1 did not touch R1 unless doing S1's regular duty such as changing R1's diapers and/or dressing R1. S1 denied smashing or whacking R1's hand at any time S1 was working with R1. LPA's interview with S2 today revealed that S2 also denied hurting R1's arm in any way. LPA's interview with R1 today revealed that it was the nurse at the hospital who sthe state’s words, verbatim · CDSS document, Sep 27, 2025 · control 31-AS-20250923134116

Allegation investigated: Staff left resident soaked in urine Staff does not ensure resident has wheelchair access to the bathroom

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint to further investigate the above allegations. LPA initially met with staff Emily Shah who called the Administrator and explained the reason for the visit. Assistant Administrator arrived 30 minutes later. LPA conducted physical plant tour at 8:30 AM, requested copy of facility documents relevant to the investigation at 9:02 AM and interviewed staff and residents between 9:30 AM to 12:00 PM. Regarding the allegation that Staff left resident soaked in urine, it was alleged that R1 was soaked in urine during Reporting Party’s (RP)’s visit. LPA's interview with R1 today at 10:02 AM, revealed that there was no time that R1 was left soaked or soiled for a long time and staff are regularly changing R1 at all times. LPA's interview with four (4) incontinent residents today revealed that four (4) out of four (4) residents interviewed stated that staff change them regularly and check on them regularly all thethe state’s words, verbatim · CDSS document, Sep 27, 2025 · control 31-AS-20250611093220

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure resident's medical needs are being met Staff does not provide resident toiletries.

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with the Assistant Administrator and explained the reason for the visit. LPA conducted a physical plant tour at 9:28 AM, requested copies of facility documents relevant to the investigation at 10:00 AM, reviewed records between 10:00 AM to 11:00 AM and interviewed staff and residents between 11:00 AM to 1:00 PM. Regarding the allegations that Staff does not provide resident toiletries, it was alleged that there are no paper towels or towels in Resident #1 (R1)'s bathroom to dry hands after washing. LPA's observation on 06/03/25 and today during physical plant tour revealed that of the nine (9) rooms visited including that or R1's, all nine (9) rooms have towels and toiletries in their room. (continued to LIC 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 20, 2025 · control 31-AS-20250529123348

Allegation investigated: Staff made an inappropriate comment towards a resident in care

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit. LPA conducted a physical plant tour at 9:28 AM, requested copies of facility documents relevant to the investigation at 9:59 AM and interviewed residents and staff between 11:10 AM to 1:00 PM. Regarding the allegation that Staff made an inappropriate comment towards a resident in care, it was alleged that Staff #1 (S1) was going to take Resident #1 (R1)’s “(marijuana) pipe” even if she has to drag R1 out of R1’s room. LPA’s record review today between 10:00 AM to 11:00 AM revealed that R1 made similar allegations on 05/16/24 under complaint control number 31-AS-20240516145438 and then again on 11/04/24 under complaint control number 31-AS-20241104113106 and both were unsubstantiated (please see report on the same date.) LPA’s interview with R1 today atthe state’s words, verbatim · CDSS document, Aug 1, 2025 · control 31-AS-20250731111405

Allegation investigated: Staff is overcharging resident Staff is not addressing facility plumbing issues Staff does not ensure resident's restroom is kept sanitary

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit. LPA conducted physical plant tour at 9:31 AM, requested copies of facility documents relevant to the investigation at 10:02 AM and interviewed residents and staff between 10:15 AM to 1:00 PM. Regarding the allegation that Staff is overcharging resident, it was alleged that Resident #1 (R1) was told that there is a $300 fine if R1 soils bedding and the facility has to provide new. LPA's record review today at 1:00 PM revealed that R1 is a client of Los Angeles County Department of Mental Health (LA DMH) and does not have a Share of Cost (SOC) or simply, R1 is not paying the facility out of pocket. LPA's interview with R1 today at 10:18 AM, revealed that it was a misrepresentation of R1's statement, R1 denied saying there was a fine at the facility. LPAthe state’s words, verbatim · CDSS document, Jun 3, 2025 · control 31-AS-20250529123348

Allegation investigated: Staff did not prevent resident from being sexually abused

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegation. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit. On 09/26/24, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted as an assignment by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Olivia Spindola to interview Resident #1 (R1). On 09/27/2024 at 9:16 AM, LPA initiated the complaint visit. LPA interviewed the assistant administrator, staff and residents and obtained copies of the facility records relevant to the investigation. (continued to LIC 9099) Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 6, 2025 · control 31-AS-20240926144530

Allegation investigated: Staff failed to ensure medication were assisted with as prescribed.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a initial complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Itzel Guevara and advised them about the visit. At 10:45 AM LPA conducted a physical plant tour to ensure the health and safety of the clients in care. An entrance interview was conducted. Allegation #1: Staff failed to ensure medication were assisted with as prescribed. It was alleged that Resident #1(R1) was not given medication (PRN) when needed as prescirbed by physician. LPA did a record review on 1.2.2025 between 11:15 AM to 12:30 PM revealed that R1 has been getting their medication on-time as precribed by the physician. Continue to LIC 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 2, 2025 · control 31-AS-20241227105933

Allegation investigated: Resident is being verbally abused while in care

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit. LPA conducted physical plant tour at 9:23 AM, requested copy of facility documents relevant to the investigation at 9:55 AM, reviewed records from 10:00 AM to 11:00 AM and interviewed staff and residents between 11:00 AM to 1:00 PM. It was alleged that Resident #1 (R1) is experiencing verbal abuse and name calling to where R1 lives. LPA's record review between 10:00 AM to 11:00 AM today revealed that R1 made the same allegation on 05/16/24 under complaint control number 31-AS-20240516145438 and was unsubstantiated. LPA's interview with R1 today at 11:37 AM revealed that R1 did not personally see or heard any of the staff verbally abusing or calling R1 names but only overheard it through the wall of R1's room. Further interview with R1 also revealed thathe state’s words, verbatim · CDSS document, Nov 5, 2024 · control 31-AS-20241104113106

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff stole resident's credit card Staff did not safeguard resident's funds.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit. LPA conducted physical plant tour at 9:05 AM, requested copies of facility documents relevant to the investigation at 9:43 AM and interviewed staff and residents between 10:00 AM to 12:00 PM. LPA also conducted record review between 12:15 PM to 1:00 PM. Regarding the allegation that staff stole resident's credit card, it was alleged that staff is taking Resident #1 (R1)'s credit cards. LPA's interview with R1 on 01/25/24 at around 12:30 PM revealed that no staff took R1's credit card and R1 kept all of R1's bank cards and denied any usage from any staff. LPA's observation also revealed that R1 had own one on one caregiver from Lanterman Regional Center five (5) days a week during daytime. LPA's interview with the R1's caregiver confirmed ththe state’s words, verbatim · CDSS document, Aug 7, 2024 · control 31-AS-20240123093103

Allegation investigated: Staff did not ensure that resident's needs were met

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit. LPA conducted physical plant tour at 9:23 AM, requested copies of facility documents relevant to the investigation at 9:54 AM, reviewed records from 10:00 AM to 11:15 AM and interviewed staff, residents, and witness between 11:30 AM to 1:10 PM. It was alleged that Staff doesn't come when needed and R1's wheelchair is broken and not being replaced. LPA's record review today revealed that R1 is a client of Frank D Lanterman Regional Center (FDLRC) since 2012. Further review also revealed that R1 is being provided a 1:1 care staff by the Regional Center for five (5) hours every day five (5) days a week. LPA's interview with R1 today at 11:30 AM revealed that R1 was aware that it was the responsibility of and following up with FLDRC for the replacement ofthe state’s words, verbatim · CDSS document, Jul 16, 2024 · control 31-AS-20240712160413

Allegation investigated: Resident was physically abused while in care

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with Administrator Itzel Guevarra and explained the reason for the visit. LPA conducted physical plant tour at 9:22 AM, requested copy of facility documents relevant to the investigation at 9:53 AM, reviewed records between 10:00 AM to 11:30 AM and interviewed staff and residents between 11:35 AM to 1:00 PM. It was alleged that Resident#1 (R1) was slapped by a caregiver's husband and threw coffee at R1. No other information was provided for this allegation. LPA made a reasonable attempt to contact the reporting party to get more details of the allegation but to no avail. LPA's record review revealed that R1 was admitted at the facility on 07/20/23 and went to the hospital due to a medical condition on 11/27/23 and discharged to a Skilled Nursing Facility (SNF) on 12/01/23. LPA's interview with the assistant administrator today at 12:06 PM reveathe state’s words, verbatim · CDSS document, Jul 2, 2024 · control 31-AS-20240628155539

Allegation investigated: Staff threatened resident Staff do not treat resident with dignity and respect

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegations. LPA met with Administrator Itzel Guevarra and explained the reason for the visit. LPA conducted physical plant tour at 9:18 AM, requested copies of facility documents relevant to the investigation at 10:24 AM and interviewed staff and residents between 11:00 AM and 1:00 PM, It was alleged that Resident #1 (R1) was threatened by a staff to throw R1 in the stairs in R1's wheelchair. LPA's interview with R1 today at 11:12 AM revealed that it wasn't a staff who threatened R1 but another resident of the facility. LPA's interview with Resident #2 (R2) who allegedly threatened R1 revealed that R2 did not know R1 and did not threaten anyone. Further interview with R1 also revealed that R1 was not threatened directly by R2 but only overheard it and did not remember when and where R1 overheard it. (continued on LIC 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 22, 2024 · control 31-AS-20240516145438

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

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 staffthe state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20230131105058

Allegation investigated: Resident sustained fracture while in care

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 visitthe state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20230130162534

Allegation investigated: Staff spat in a residents drink.

Licensing Program Analysts (LPAs) Gary Tan and Ray Comer conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPAs met with administrator Itzel Guevarra and explained the reason for the visit. LPAs conducted a physical tour at 9:09 AM, requested copies of facility documents relevant to the investigation at 9:33 AM and interviewed staff and residents between 10:00 AM to 12:30 AM. Regarding the allegation that Staff spat in a resident’s drink, it was alleged that Resident #1 (R1) watched the staff members spit in R1's drink. LPAs' interview with Resident #1 (R1) today at 10:00 AM revealed that R1 did not witness any staff mentioned on the report spitting on R1's drink and R1 just "tasted" the saliva on the drink. LPAs' record review today revealed that all the staff mentioned are kitchen staff and four (4) out of four (4) staff has current State Food Handling certificate on file. LPAs' interview with the four (4) kitchen staff also revealthe state’s words, verbatim · CDSS document, Mar 28, 2024 · control 31-AS-20240320145828

Allegation investigated: Staff does not ensure facility is free of pest.

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 Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 16, 2024 · control 31-AS-20240207092211

Allegation investigated: Staff are not following resident's dietary plan

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with administrator Itzel Guevarra and explained the reason for the visit. LPAs conducted physical plant tour at 11:35 AM, requested copies of facility documents relevant to the investigation at 12:02 PM and interviewed staff and resident between 12:20 PM to 1:45 PM. Regarding the allegation that Staff are not following resident's dietary plan, it was alleged that staff are ignoring Resident #1 (R1)'s dietary restriction is being ignored by the staff. LPAs' record review at 12:15 PM revealed R1 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. Based on the information gathered during this visit. The allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issuethe state’s words, verbatim · CDSS document, Jan 25, 2024 · control 31-AS-20240123093103

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.