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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002894
Report Date: 11/13/2025
Date Signed: 11/13/2025 11:58:59 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2025 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20250925163842
FACILITY NAME:GOLDEN HILLS CARE HOMEFACILITY NUMBER:
315002894
ADMINISTRATOR:MAHAJAN, VIVEKFACILITY TYPE:
740
ADDRESS:1434 ELM STREETTELEPHONE:
(916) 474-4920
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 5DATE:
11/13/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Caregiver/ designee LouisTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee does not ensure resident files are properly managed
INVESTIGATION FINDINGS:
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On 11/13/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Louis Dizon, designee to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted interviews.
LPA finds that the allegations cited above are substantiated.
Records review and interview found that on R1 had a fall that required assessment and lift assist by emergency responders. LPA records review found R1's file to be incomplete- lacking admission agreement, ID and emergency contact information and a pre-appraisal.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Admin . Copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
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 3
Control Number 59-AS-20250925163842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 315002894
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2025
Section Cited
CCR
87506(a)
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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met based on records review.
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Licensee will submit a statement identifying all records to be in resident files at the facility upon admission of a new resident by the POC date of 12/11/25.
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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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2025 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20250925163842

FACILITY NAME:GOLDEN HILLS CARE HOMEFACILITY NUMBER:
315002894
ADMINISTRATOR:MAHAJAN, VIVEKFACILITY TYPE:
740
ADDRESS:1434 ELM STREETTELEPHONE:
(916) 474-4920
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 5DATE:
11/13/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Caregiver/ designee LouisTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Licensee does not ensure the administrator is on the premises a sufficient number of hours to oversee operations of the facility
INVESTIGATION FINDINGS:
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On 11/13/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Louis Dizon, designee.

LPA conducted records review and interviews.
LPA is unable to find and or meet the preponderance, per policy.
Interviews found that while Administrator may have had periods of not being present at the facility, the house lead had access to the Administrator when needed for operations and care of residents. Issues related to the administrator's absence have been resolved and a new LIC 500 for all staff will be submitted.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with Admin.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
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 3