197609631-5-13-2026-31-AS-TAGD-DXQSRT-20260908140653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 05/13/2026
Date Signed: 05/13/2026 02:23:18 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
05/07/2026 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20260507112329

FACILITY NAME:	GOLDEN HILLS RETIREMENT CTR INC		FACILITY NUMBER:	197609631
ADMINISTRATOR:	GUEVARA, ITZEL		FACILITY TYPE:	740
ADDRESS:	10159 HILLHAVEN AVE		TELEPHONE:	(818) 352-1559
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	60	CENSUS: 52	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Itzel Guevarra - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff left resident soiled for an extended period of time

Staff did not respond to residents call for help

Staff did not ensure documents are not accessible to residents

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 allegations. LPA met with Administrator Itzel Guevarra and explained the reason for the visit.

LPA conducted physical plant tour at 9:20 AM, requested copies of facility documents at 9:49 AM, reviewed records between 10:00 AM to 11:00 AM and interviewed staff and residents between 11:00 AM to 1:15 PM. Regarding the allegation that Staff left resident soiled for an extended period of time, it was alleged that Resident #1 (R1) was found covered in own urine when the Agency Staff arrived on shift. LPA's record review today between 10:00 AM to 11:00 AM revealed that on 04/28/26 the facility staff changed R1's diaper to 1:20 AM, 3:00 AM, 5:40 AM, 7:00 AM and 9:05 AM., or immediately after the arrival of Agency Staff at 9:00 AM. LPA's interview with four (4) other incontinent residents today between 11:00 AM to 2:30 PM revealed that four (4) out of four (4) residents interviewed stated that they are being changed regularly by staff all the time including nights. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260507112329

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: 05/13/2026

NARRATIVE

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(continued from LIC 9099-C)

Regarding the allegation that Staff did not respond to residents call for help, it was alleged that R1 called for help and needed assistance to change but help did not arrive. LPA's interview with R1 today at 11:29 AM revealed that whenever R1 needed help staff always come. LPA's interview with Staff #1 (S1) today at 12:45 PM revealed that S1 regularly checked on R1 during shift and did not get any call from R1 at any time during S1's shift. LPA's interview with four (4) other incontinent residents today between 11:00 AM to 2:30 PM revealed that four (4) out of four (4) residents interviewed stated that staff always come to help whenever they call at any time.

Regarding the allegation that Staff did not ensure documents are not accessible to residents, it was alleged that the facility did not present any logs of the rounds they do every two hours during the night, rather they said a resident goes into the office and takes their documents to draw on. LPA's observation during today's visit revealed that the Incontinent log was always kept in the office to be accessible to all caregivers to sign on every after routine checks to all residents but this particular resident (R2) always picks up any paper near or by the office and write/draw on them. LPA's interview with staff and Administrator revealed that the Incontinent log was located at the table in the office and R2 reached out from the window to open the office and took the Incontinent log and drew on them. The log did not have any information aside from the name of the resident and the time and staff initials when they did the routine check on the resident.

Based on the information gathered during this 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: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

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