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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 09/27/2025
Date Signed: 09/27/2025 01:57:01 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
09/23/2025 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20250923134116
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:
09/27/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Adriana Cisneros - Assistant AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint to further investigate the above allegations. LPA initially met with staff Emily Shah who called the Administrator and explained the reason for the visit.

LPA conducted physical plant tour at 12:30 PM, requested copy of facility documents relevant to the investigation at 12:50 PM and interviewed staff and resident between 12:50 PM to 1:30 PM. Regarding the allegation that Staff hit resident, it was alleged that Staff #1 (S1) and Staff #2 (S2) were "whacking" and "smashing" Resident #1 (R1)'s hands repeatedly. LPA's interview with S1 on 09/25/25 revealed that S1 did not touch R1 unless doing S1's regular duty such as changing R1's diapers and/or dressing R1. S1 denied smashing or whacking R1's hand at any time S1 was working with R1. LPA's interview with S2 today revealed that S2 also denied hurting R1's arm in any way. LPA's interview with R1 today revealed that it was the nurse at the hospital who smashed R1's hand over and over again and denied any staff at the facility hurting R1. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2025
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-20250923134116
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: 09/27/2025
NARRATIVE
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(continued from LIC 9099)

Based on the information gathered during this and prior 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: 09/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2