197609621-7-13-2021-31-AS-NMAN-C57N3R-20210723100646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 07/13/2021
Date Signed: 07/13/2021 05:30:11 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
07/21/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200721163341

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: 110	DATE:	07/13/2021
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Monique Lopez Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was left outside in the sun resulting in hospitalization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with administrator Monique Lopez and explained the reason for the visit.

LPA conducted physical plant tour at 12:45 PM, reviewed facility records at 1:30 PM and conducted interview with the administrator and staff of the facility at 2:55 PM. LPA observation during physical plant tour revealed that Resident #1 (R1) collapsed and fell at the side walk near the front entrance of the neighboring Skilled Nursing and Rehabilitation facility approximately one hundred fifty (150) meters away from the front door of this facility. LPA record review also revealed that R1 left the facility at 10:25 AM on 07/19/20. Further, R1 was able to leave the facility unassisted. LPA interview with the administrator also confirmed that R1 was independent and was never left outside and regularly went out of the facility to shop or ran own's errand. Based on the information gathered during this and prior visit. The allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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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