<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:13:51 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
11/04/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20241104113106
FACILITY NAME:GOLDEN HILLS RETIREMENT CTR INCFACILITY NUMBER:
197609631
ADMINISTRATOR:GUEVARA, ITZELFACILITY TYPE:
740
ADDRESS:10159 HILLHAVEN AVETELEPHONE:
(818) 352-1559
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:60CENSUS: 36DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Adriana Cisneros - Assistant AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is being verbally abused while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 that R1 narrated the same things that R1 told the LPA during the interview on the prior complaint stated above. (continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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 2
Control Number 31-AS-20241104113106
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: 11/05/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(continued from LIC 9099)

LPA's interview with three (3) staff today between 11:00 AM to 1:00 PM revealed that no one among the three (3) staff witnessed anyone calling R1 names or yelling or verbally abusing R1. Further, all the staff interviewed denied calling R1 names, yelled or verbally abused R1. LPA's interview with four (4) residents today between 11:00 AM to 1:00 PM revealed that all of them did not experience being called names, yelled at, or verbally abused by any staff nor witnessed any staff calling names, verbally abusing, or yelling at any resident.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2