197609621-8-22-2021-31-AS-NMAN-C7668Z-20210923203558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 08/21/2021
Date Signed: 08/22/2021 10:02:08 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
01/12/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210112082952

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:	08/21/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Amourfino Cruz - Staff		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide proper care for resident

Resident does not have reasonable access to telephone

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 staff Amourfino Cruz and explained the reason for the visit.

LPA conducted physical plant tour at 11:30 AM, requested facility documents relevant to the investigation at 12:15 PM and interviewed residents between 12:15 PM to 2:30 PM. Regarding the allegation that Staff did not provide proper care for resident, LPA's interview with Resident #1 (R1) on 01/20/21 at 12:30 PM and today at 12:20 PM, revealed that staff are providing appropriate care and attending to R1's needs. LPA's interview with R1's room mate, Resident #2 (R2) confirmed that the staff are monitoring and attending to R1's needs and provide proper care. LPA interview with staff at 1:00 PM today, also revealed that staff are checking on R1 regularly to change R1's diapers when needed and to ensure R1's well being.

(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: 08/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2021

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-20210112082952

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: 08/21/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Resident does not have reasonable access to telephone, LPA's interview with R1 revealed that R1 did not have any problem using the telephone and has own cell phone to use. LPA's interview with eleven (11) residents or more than 10% of the current census, revealed that residents have access to the facility phone anytime and did not have any problem using the facility phone.

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: 08/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2021

LIC9099 (FAS) - (06/04)

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