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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 10/28/2025
Date Signed: 10/28/2025 01:52:51 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
10/20/2025 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20251020105302
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: 45DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Adriana Cisneros - Assistant AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff administering unprescribed medication to resident.
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 allegation. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit.

LPA conducted a physical plant tour at 9:30 AM, requested copies of facility documents relevant to the investigation at 9:58 AM, reviewed records between 10:05 AM to 11:15 AM and interviewed residents and staff between 11:15 AM to 1:00 PM. Regarding the allegation that Staff administering unprescribed medication to resident, it was alleged that staff are crushing up a medication called Taminal and put it into Resident #1 (R1)'s food. LPA's interview with R1 today at 12:18 PM, revealed that the staff did not give R1 unprescribed medication, R1 was given a medication that is called Klonopin (Clonazepam) that is blue in color but now the staff are giving R1 a green colored pill which they say is the same medication. LPA's record review today at 10:05 AM, revealed that Klonopin is a Pro Re Nata (PRN) medication or only given as needed for R1 and the pill color is green. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
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-20251020105302
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: 10/28/2025
NARRATIVE
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(continued from LIC 9099)

LPA's observation during inspection of R1's medication confirmed that all Klonopin (1 mg) pills are green in color compared to other residents' medication of the same name. LPA's interview with staff today between 11:15 AM to 1:00 PM revealed that the same medication used to be color blue but the pharmacy is sending them the green ones, both two (2) medication staff interviewed denied crushing any pill for R1 as they have no doctor's order for it. LPA's record review confirmed that there was no order for R1 to be given a crushed pill.

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: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2