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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006529
Report Date: 12/30/2024
Date Signed: 01/02/2025 08:35:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2024 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241224104548
FACILITY NAME:GOLDEN HEARTS ELDERLY CARE 2FACILITY NUMBER:
306006529
ADMINISTRATOR:ELAHI, NARGISFACILITY TYPE:
740
ADDRESS:25231 ROMERA PLACETELEPHONE:
(949) 716-0016
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 3DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Nargis Elahi, Licensee/Administrator TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Licensee did not follow proper eviction procedure
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry by Caregiver Noor Elahi and explained the reason for the visit. Administrator/Licensee Nargis Elahi arrived shortly after.

The Department received a complaint on 12/24/2024 and initial 10 day visit was conducted on 12/30/2024. During the visit, LPA Mendivil obtained copies of documents including medication adminstration record and admission agreement. LPA Mendivil interviewed staff and residents. Regarding the allegation licensee does not follow proper eviction procedure, the investigation revealed the following:

It was alleged that facility is not following eviction procedures. Based on interviews with witnesess it was alleged the facility issued a 10 day evicition notice. Based on interviews with Administrator/Licensee Nargis it was reported that they have the right to issue a 3 day eviction if they are not able to meet the residents' needs.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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 5
Control Number 22-AS-20241224104548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN HEARTS ELDERLY CARE 2
FACILITY NUMBER: 306006529
VISIT DATE: 12/30/2024
NARRATIVE
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Administrator/Licensee Nargis stated that they have never had to issue out an eviction and was under the impression she could issue an eviction sooner than 30 days if they are not meeting the resident's needs.

Therefore, based on a preponderance of evidence through interviews and records reviewed the allegation Licensee did not follow proper eviction procedure, is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2024 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20241224104548

FACILITY NAME:GOLDEN HEARTS ELDERLY CARE 2FACILITY NUMBER:
306006529
ADMINISTRATOR:ELAHI, NARGISFACILITY TYPE:
740
ADDRESS:25231 ROMERA PLACETELEPHONE:
(949) 716-0016
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 3DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Noor Elahi - Caregiver TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility does not have sufficient overnight staffing
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry by Caregiver Noor Elahi and explained the reason for the visit. Administrator/Licensee Nargis Elahi arrived shortly after.

The Department received a complaint on 12/24/2024 and initial 10 day visit was conducted on 12/30/2024. During the visit, LPA Mendivil obtained copies of documents including medication adminstration record and admission agreement. LPA Mendivil interviewed staff and residents. Regarding the allegation facility does not have sufficient overnight staffing, the investigation revealed the following:

Based on interviews with Licensee/Administrator Nargis she stated there is always staff at the facility and they are available overnight for emergencies/as needed. Licensee Nargis stated they do not have awake overnight staff. Licensee Nargis stated they have motion censors in the rooms which notifies staff via a bell system which they would respond to.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20241224104548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN HEARTS ELDERLY CARE 2
FACILITY NUMBER: 306006529
VISIT DATE: 12/30/2024
NARRATIVE
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Therefore, based on the preponderance of evidence through interviews the allegation that Facility does not have sufficient overnight staffing is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.
No deficiencies cited.

An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20241224104548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN HEARTS ELDERLY CARE 2
FACILITY NUMBER: 306006529
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
87224(a)(4)
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(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...4) If, after admission, it is determined that the resident has a need not previously identified...
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Licensee reviewed 87224 Eviction Procedures and provided a signed copy of acknowledgement.
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... and a reappraisal has been conducted pursuant to Section 87463. This requirement was not met as evidence by Licensee/Administrator issued a 10 day notice, this poses a potential risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5