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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 08/01/2025
Date Signed: 08/01/2025 01:56:41 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
07/31/2025 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20250731111405
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: 44DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Itzel Guevarra - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff made an inappropriate comment towards a resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose 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 a physical plant tour at 9:28 AM, requested copies of facility documents relevant to the investigation at 9:59 AM and interviewed residents and staff between 11:10 AM to 1:00 PM. Regarding the allegation that Staff made an inappropriate comment towards a resident in care, it was alleged that Staff #1 (S1) was going to take Resident #1 (R1)’s “(marijuana) pipe” even if she has to drag R1 out of R1’s room. LPA’s record review today between 10:00 AM to 11:00 AM revealed that R1 made similar allegations on 05/16/24 under complaint control number 31-AS-20240516145438 and then again on 11/04/24 under complaint control number 31-AS-20241104113106 and both were unsubstantiated (please see report on the same date.) LPA’s interview with R1 today at 11:15 AM revealed that S1 did not directly tell R1 but heard S1 over the speaker on the wall of R1's room. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
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-20250731111405
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: 08/01/2025
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-C)

LPA’s observation during physical plant tour revealed that there is no speaker on R1's room wall or any resident's room anywhere. LPA's interview with Resident #2 (R2) or R1's roommate today at 11:59 AM today revealed that R2 did not experience nor witness S1 saying inappropriate comments at anyone.

LPA’s interview with a total of four (4) residents or 10% of current census revealed that four (4) out of four (4) residents interviewed did not experience or witness S1 saying inappropriate comments to anyone at the facility.

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: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2