197609621-5-10-2021-31-AS-NMAN-C6XTWB-20210917150517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 05/08/2021
Date Signed: 05/10/2021 07:32:35 AM

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
01/25/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210125162348

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: 116	DATE:	05/08/2021
		UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Marilyn Nguyen - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff threatened resident

INVESTIGATION FINDINGS:

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

LPA conducted initial virtual visit on 01/29/21. During the initial visit, LPA interviewed the administrator and obtained copy of facility documents. During today's visit, LPA conducted physical plant tour at around 8:40 AM and interviewed staff at 9:09 AM. At 10:40 AM, LPA interviewed Resident #1 (R1). LPA interview with R1 revealed that R1 admitted to have been inside the kitchen wherein only staff were allowed. LPA interview with the administrator and licensee revealed that R1 was verbally warned of not going inside the kitchen and was issued a written notice, not an eviction letter. Further, interview with R1 also revealed that R1 has since apologized and did not go inside the kitchen again. 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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021

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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