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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 01/02/2025
Date Signed: 01/03/2025 08:50:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/27/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20241227105933
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: 35DATE:
01/02/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Adriana Cisneros- Assistant AdministratorTIME COMPLETED:
01:37 PM
ALLEGATION(S):
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Staff failed to ensure medication were assisted with as prescribed.
INVESTIGATION FINDINGS:
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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
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
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 2
Control Number 31-AS-20241227105933
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN HILLS RETIREMENT CTR INC
FACILITY NUMBER: 197609631
VISIT DATE: 01/02/2025
NARRATIVE
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At 11:30 AM LPA interview with three (3) staff on 1.2.2025 confirmed that R1 called 911 on 11.29.2024 by themselves and was brought to the hospital for breathing issues. Upon discharged R1 was adamant about getting Clonazepam for a refill, that was just prescribed for only 14 days. Refill request was denied by prescribing physician and/ or primary care physician (PCP); which made R1 was very upset with the facility. LPA interview seven (7) out of thirty-five (35) residents who were at the facility and it was revealed that medication were given on-time to all the residents with the right dosage. A review of R1’s Medication Administration Record (MAR) supported the information received from staff. Therefore, residents interview revealed that staff do administer medications as prescribed and on time.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2