197609621-5-12-2021-31-AS-NMAN-C74VVB-20210922164602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 05/12/2021
Date Signed: 05/12/2021 02:39:32 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
05/04/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210504144444

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:	05/12/2021
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Lack of supervision resuting in resident being physically assaulted by other resident in care
Staff withheld resident's medication
Staff withheld food from resident
Facility has insects
Resident is not provided with clean towels
Masks are not being worn to prevent the spread of COVID-19

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan and Patrick Shanahan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with administrator Monique Lopez and explained the reason for the visit.

At 9:15 AM, LPAs conducted physical plant tour. At 10:30 AM, LPAs interviewed residents and staff of the facility and at 11:17 AM, reviewed facility records and obtained copies of pertinent documents relevant to the investigation. Regarding the allegation that lack of supervision resulting in resident being physically assaulted by other resident in care, LPAs interview with Resident #1 (R1) revealed that R1 alleged that another resident assaulted R1 but was not able to provide any detail as to when or who or how it happened.

Regarding the allegation that Staff withheld medication, LPAs interview with R1 revealed that R1 kept most of own medication except for PRN. LPAs record review revealed that R1 is able to administer own and PRN medication. Further, medication log review also revealed that R1 refused to take own medication.

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: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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-20210504144444

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: 05/12/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that staff withheld food with resident, LPAs interview with R1 revealed that by R1's own admission, that R1 did not eat at the facility and bought own food. LPAs interview with staff confirmed that R1 does not eat at the dining area but was never refused any food if and when R1 asked for it. R1 also confirmed that although R1 does not receive food from the facility, when R1 is hungry, food will be provided to R1.

Regarding the allegation that the facility has insects, LPAs interview with R1 revealed that insects only came in at night so nothing is visible during the day. LPA record review revealed that the facility has contracted a pest control to visit monthly to prevent any infestation. Further, pest control invoices showed all common areas and fifteen (15) rooms are being treated monthly. LPA interview with administrator also revealed that if they received a report from resident about any infestation, the pest control gives priority to the reported room and/or area.

Regarding the allegation that resident is not provided with clean towels, LPAs interview with twelve (12) residents in conjunction with the same allegation complaint control no.: 31-AS-20210413133124 (please see report dated 04/16/21) revealed that the staff provide fresh towel daily. LPAs observation during today's and 04/16/2021 visit also revealed that R1 has fresh towels in own bathroom.

Regarding the allegation that masks are not being worn to prevent the spread of COVID-19, LPAs observation during this and prior visits revealed that all the staff are wearing masks while working inside the facility. Some of the residents however were observed not wearing masks. LPAs interview with the administrator revealed that they always remind resident and provided them with masks but they refused to wear masks.

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

Exit interview conducted, copy of this report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

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