197609621-6-1-2020-31-AS-MVAO-BQ9NH7-20200604102816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 05/28/2020
Date Signed: 06/01/2020 01:53:02 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
03/10/2020 and conducted by Evaluator Jose Gary Tan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200310081412

FACILITY NAME:	GOLDEN ASSISTED LIVING		FACILITY NUMBER:	197609621
ADMINISTRATOR:	LOPEZ, MONIQUE		FACILITY TYPE:	740
ADDRESS:	14060 ASTORIA ST		TELEPHONE:	(818) 367-1947
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	128	CENSUS: 103	DATE:	05/28/2020
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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9

Facility is not providing a safe environment for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Monique Lopez.

LPA Tan conducted physical plant tour, reviewed facility records and conducted interview with administrator, staff and residents of the facility. LPA interview with Resident #1 (R1) revealed that no one saw Resident #2 (R2) being aggressive or threatened R1. R2 denied being aggressive or threatened R1 at anytime. LPA interview with staff also revealed that R2 had never had any incident at the facility and was quiet and kept to R2's self. Based on the information gathered during the course of the investigation, the allegation is deemed unsubstantiated at this time.

A telephonic exit interview was conducted with Monique and a hard copy was provided via email for signature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

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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