197609621-9-4-2021-31-AS-NMAN-C75245-20210922170323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 09/04/2021
Date Signed: 09/04/2021 04:29:45 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
03/10/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210310104813

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: 105	DATE:	09/04/2021
		UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Marilyn Nguyen - Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff do not provide resident with proper assistance
Resident's hygiene needs are not being met
Staff refuse to give resident medication

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 allegations. LPA met with administrator Marilyn Nguyen and explained the reason for the visit.

LPA conducted physical plant tour at 9:30 AM. Requested facility documents relevant to the investigation at 10:30 AM and conducted interview with staff and residents between 10:30 AM to 2:00 PM. Regarding the allegation that the Staff do not provide resident with proper assistance, LPA record review at 2:00 PM, revealed that Resident #1 (R1) was able to bathe, dress/groom and care for own toileting needs and able to leave the facility unassisted. LPA's interview with Resident #2 (R2) who is the room mate of R1 for eight (8) months at 1:35 PM, revealed that R1 always leave the facility early in the morning and arrive at between 6:00 PM to 7:00 PM every day of the week and that staff always assist R1 with all of R1's needs and always attend to R1 whenever R1 needed assistance. (continued on LIC 9099-C)

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: 09/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2021

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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Control Number 31-AS-20210310104813

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 ASSISTED LIVING	FACILITY NUMBER: 197609621
	VISIT DATE: 09/04/2021

NARRATIVE

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(continued from LIC 9099)

LPA's closed circuit television (CCTV) footage review at 10:55 AM, confirmed that R1 leaves early in the morning and arrives at the facility between 6:00 PM to 7:00 PM. Moreover, LPA's interview with care staff between 11:00 AM to 2:00 PM, also revealed that whenever R1 arrived at the facility, staff assist R1 to clean and provide R1's medication.

Regarding the allegation that resident's hygiene needs are not being met, LPA's record review revealed that R1 is able to bathe, dress/groom and care for own toileting needs. LPA's interview with R2 revealed that R2 reminded R1 daily to stay to have shower and clean but R1 refused and leave the facility early in the morning everyday of the week. Further, staff always clean R1 upon arrival at the facility but sometime R1 refused. LPA interview with staff also revealed that when cleaning R1, staff offered R1 to shower but sometimes refused.

Regarding the allegation that Staff refuses to give resident medication, LPA's record review revealed that all of R1's prescribed medication were given to R1, but LPA's interview with R2 revealed that R1 refused to bring medication when leaving the facility early in the morning. Further, all of the six (6) medications of R1 are prescribed to be taken once a day and could be taken any time of the day except for one that needed to be taken during bedtime. LPA's review with three (3) care staff also revealed that R1 always take own medication upon arrival at the facility before going to own room.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2021

LIC9099 (FAS) - (06/04)

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