197609631-6-3-2025-31-AS-TAGD-DMQTEB-20251023143939

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 06/03/2025
Date Signed: 06/03/2025 01:53:16 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
05/29/2025 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20250529123348

FACILITY NAME:	GOLDEN HILLS RETIREMENT CTR INC		FACILITY NUMBER:	197609631
ADMINISTRATOR:	GUEVARA, ITZEL		FACILITY TYPE:	740
ADDRESS:	10159 HILLHAVEN AVE		TELEPHONE:	(818) 352-1559
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	60	CENSUS: 40	DATE:	06/03/2025
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Adriana Cisneros - Assistant Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff is overcharging resident

Staff is not addressing facility plumbing issues

Staff does not ensure resident's restroom is kept sanitary

INVESTIGATION FINDINGS:

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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. LPA's interview with the Assistant Administrator (AA) today at 11:04 AM revealed that AA is not aware of any fine at the facility nor they impose any fine at any resident at any time. (continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250529123348

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: 06/03/2025

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff is not addressing facility plumbing issues, it was alleged that R1 was informed that the facility has very bad plumbing. LPA's observation during physical plant tour at around 9:31 AM, revealed that there was no issue on R1's room plumbing, LPA tested that toilet multiple times and the bathroom sink and shower too and did not observe anything wrong or there is any plumbing issue at R1's bathroom. LPA's interview with R1 today with revealed that there is no plumbing issue at R1's room and was only told by the staff of the probable issue with plumbing. LPA's interview with R2 or R1's roommate confirmed that there was no plumbing issue in their bathroom

Regarding the allegation that Staff does not ensure resident's restroom is kept sanitary, it was alleged that
R1 has been using Depends (Pull up Diaper), that R1 will wear the same item for weeks on end for fear that there is nowhere or no process to dispose of it. LPA's record review today revealed that R1 has no bladder and/or bowel impairment, ambulatory and has the capacity for self-care including but not limited to bathing, dressing, grooming and toileting. LPA's interview with R1 today revealed that R1 used Depends sparingly at R1's own volition only. R1 stated that R1 goes to the bathroom on R1's own and able to take care of own toileting needs and denied being incontinent. LPA's observation during physical plant tour revealed that there is a trash can with lid at R1's bathroom.

Based on the information gathered during this visit, these allegations are 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: 06/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC9099 (FAS) - (06/04)

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