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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 03/28/2024
Date Signed: 03/28/2024 01:53:40 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
03/20/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240320145828
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: 39DATE:
03/28/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Itzel Guevarra - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff spat in a residents drink.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gary Tan and Ray Comer conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPAs met with administrator Itzel Guevarra and explained the reason for the visit.

LPAs conducted a physical tour at 9:09 AM, requested copies of facility documents relevant to the investigation at 9:33 AM and interviewed staff and residents between 10:00 AM to 12:30 AM. Regarding the allegation that Staff spat in a resident’s drink, it was alleged that Resident #1 (R1) watched the staff members spit in R1's drink. LPAs' interview with Resident #1 (R1) today at 10:00 AM revealed that R1 did not witness any staff mentioned on the report spitting on R1's drink and R1 just "tasted" the saliva on the drink. LPAs' record review today revealed that all the staff mentioned are kitchen staff and four (4) out of four (4) staff has current State Food Handling certificate on file. LPAs' interview with the four (4) kitchen staff also revealed that none of them spat on any residents' food and/or drink nor witness any other staff spat on any resident's food and/or drink. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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-20240320145828
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: 03/28/2024
NARRATIVE
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(continued from LIC 9099)

LPAs' interview with four (4) random residents today between 10:00 AM to 1:00 PM revealed that four (4) out of four (4) residents did not witness any staff spitting on any resident's food and/or drink at any time.

Based on the information gathered during this visit. The allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2