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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610541
Report Date: 11/12/2025
Date Signed: 11/12/2025 01:53:08 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
08/27/2025 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20250827170110
FACILITY NAME:GODSON HOMEFACILITY NUMBER:
197610541
ADMINISTRATOR:AMIZE, GIBSON EJIKEFACILITY TYPE:
735
ADDRESS:13637 DRONFIELD AVENUETELEPHONE:
(818) 833-7419
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:4CENSUS: 4DATE:
11/12/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Gibson Amize - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure resident's medication was taken as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Administrator Gibson Amize and explained the reason for the visit.
LPA conducted a physical plant tour at 9:13 AM, requested copies of facility documents relevant to the investigation at 9:42 AM and interviewed staff and residents between 10:00 AM to 12:30 PM. Regarding the allegation that Staff did not ensure resident's medication was taken as prescribed, it was alleged that direct care staff (DSP) did not assist medication administration for Residents #1 (R1) and Resident #2 (R2). LPA's record review today revealed that R1 had missed PM medication on 08/20/25 and AM medication on 08/21/25. LPA's interview with the co Administrator revealed that R1 took own AM medication on 08/20/25 and left the facility to visit family or collect recyclables, which R1 does every day but always comes home in time for dinner. On 08/21/25 at 1:30 AM R1 called the facility to inform them that R1 would spend the night with family and did not come home. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
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-20250827170110
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: GODSON HOME
FACILITY NUMBER: 197610541
VISIT DATE: 11/12/2025
NARRATIVE
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(continued from LIC 9099)

At around 9:00 AM of 08/20/25, the co-Administrator called R1 and was told that R1 was coming home but did not until 10:00 PM on the same day, missing R1's AM medication.

Further record review also revealed that R2 also missed medication on 08/19/25 and 08/20/25. R1 is taking only one (1) medication to be taken in the morning. LPA's interview with the co-Administrator revealed that R2 left very early (6:00 AM) on the mornings of 08/19/25 and 08/20/25, that's why R1 missed medication. When asked by the co Administrator why R1 was leaving early, R1 replied that R1 is looking for a job and R1 is not sick, that is why R1 is not taking medication despite the verbal reminder. LPA's interview with R1 confirmed R1's statement that R1 "is not sick" so R1 did not take medication. LPA's further interview with the Co Administrator today revealed that though R1 said that R1 is compliant with medication and did not miss any more aside from those two (2) days.

Based on the information gathered during this and prior visit, this 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: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2