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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 08/20/2025
Date Signed: 08/20/2025 02:08:46 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 INCFACILITY NUMBER:
197609631
ADMINISTRATOR:GUEVARA, ITZELFACILITY TYPE:
740
ADDRESS:10159 HILLHAVEN AVETELEPHONE:
(818) 352-1559
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:60CENSUS: 44DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Adriana Cisneros - Assistant AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff does not ensure resident's medical needs are being met

Staff does not provide resident toiletries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with the Assistant Administrator 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 10:00 AM, reviewed records between 10:00 AM to 11:00 AM and interviewed staff and residents between 11:00 AM to 1:00 PM. Regarding the allegations that Staff does not provide resident toiletries, it was alleged that there are no paper towels or towels in Resident #1 (R1)'s bathroom to dry hands after washing. LPA's observation on 06/03/25 and today during physical plant tour revealed that of the nine (9) rooms visited including that or R1's, all nine (9) rooms have towels and toiletries in their room.

(continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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-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: 08/20/2025
NARRATIVE
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(continued from LIC 9099)

LPA's interview with five (5) residents or more than 10% of current census revealed that five (5) out of five (5) residents interviewed were provided with towels and toiletries everyday by the staff and if they need more, they always ask the office and they are provided with toiletries including but not limited to soap, shampoo & deodorant.

Regarding the allegation that Staff does not ensure resident's medical needs are being met, it was alleged that R1 was supposed to be given the opportunity to go to the hospital lab to get stool samples so that R1 can be further tested with regards to R1's chronic medical condition. To date this still hasn't happened and it can't be left for R1 to figure out. LPA's interview with R1 on 06/23/25 at around 11:00 AM revealed that R1 was the one who supposed to make the appointment to the medical test but hasn't done so yet. LPA's interview with R1's Social worker from non-governmental agency that helps R1 for all medical appointments and transport revealed that they were the ones responsible to make an appointment and bring R1 to any medical or diagnostic appointments and not the facility.

Based on the information gathered during this and prior visit, these allegations are 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: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2