191222267-3-2-2021-31-AS-MVAO-C4GPBP-20210630111039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191222267
Report Date: 03/02/2021
Date Signed: 03/02/2021 04:41:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/25/2020 and conducted by Evaluator Martina Berry

COMPLAINT CONTROL NUMBER: 31-AS-20201125163458

FACILITY NAME:	GOLDEN YEARS		FACILITY NUMBER:	191222267
ADMINISTRATOR:	MUDER, EVANGELIA		FACILITY TYPE:	740
ADDRESS:	15822 MAYALL ST.		TELEPHONE:	(818) 892-4467
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 3	DATE:	03/02/2021
		UNANNOUNCED	TIME BEGAN:	01:51 PM
MET WITH:	Evangelia Muder		TIME COMPLETED:	02:32 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained an injury to the face.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Martina Berry conducted a subsequent complaint visit to deliver findings for the allegation above. Due to the situation surrounding Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, this visit was conducted virtually. The LPA met with Administrator Evangelia Muder and explained the reason for the visit. The investigation of the above noted allegation was conducted by the Investigator Lorraine Patterson from the Community Care Licensing Division Investigations Branch (CCLD IB).

Allegation: Resident sustained an injury to the face.

It was alleged that resident (R1) sustained injury to the face while at the facility due to neglect and lack of supervision. To investigate this allegation, the investigator obtained medical records, reviewed the resident's file, and interviewed facility residents and staff. The investigator reviewed medical records on 12/10/20. Medical records revealed that R1 sustained a fall on 11/19/20, but received prompt medical care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

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-20201125163458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS	FACILITY NUMBER: 191222267
	VISIT DATE: 03/02/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Doctors noted no concerns with neglect. Medical records documented follow up completed by doctors on 11/20/20, the day after the incident. It was reported that R1 had returned to the facility and there were no concerns.

The investigator conducted file review on 12/1/20. obtained revealed that R1 requires assistance with all activities of daily living due to medical diagnoses. R1 is non-ambulatory due to medical condition. Interviews with residents and staff were conducted on 2/2/21. Interviews revealed that R1 sustained injuries due to an accidental fall. Residents and staff interviewed did not suspect neglect. Based on information obtained from interviews and record review, the is insufficient evidence support the allegation. Therefore, the allegation is found unsubstantiated.

An exit interview was conducted with Administrator Evangelia Muder. No deficiencies cited. A copy of this report was provided via email for signature.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2