197609621-10-12-2021-31-AS-CHAS-C92RLV-20211123120745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:09:36 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
10/08/2021 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20211008102848

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: 106	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Monique Lopez		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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1. Facility staff are not ensuring resident receives food
2. Facility staff are not assisting resident with showering needs

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA)(s) Tuesday Cabiness, LaQueena Lacy, and Eleza Jackson, conducted an unannounced complaint investigation, and met with Administrator Monique Lopez. LPAs informed her the reason of the visit. The following was determined:

Allegation # 1: Facility staff are not ensuring resident receives food: During today's visit, from 10am to 115pm, LPA (s) conducted interviews with residents and staff, as well as obtained facility and client file records pertaining to the complaint. Through the information obtained, it was reported that resident # 1 (R1) receives (3) meals a day. R1, also confirmed to LPA, that the facility provides food for R1. Although R1 has occasionally refused meals; it was reported facility does ensure R1 receive food. Also,R1 confirmed to LPA (s) that the faciliy provides R1 with meals inside R1's room. And through additional interviews with residents, it was revealed that the facility provides food to all residents. Therefore, based on interviews, the allegation

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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-20211008102848

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: 10/12/2021

NARRATIVE

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the allegation "Facility staff are not ensuring that resident receives food" is UNSUBSTANTIATED at this time.

Allegation # 2: Facility staff are not assisting resident with showering needs: During today's visit, from 10am to 1pm, LPA (s) conducted interviews with residents and staff, as well as obtained facility and client file records pertaining to the complaint. Through the information obtained, it was reported that resident # 1 (R1) receives two assisted showers a week, including an additional shower if requested. R1 also confirmed to LPA that R1 receives showers weekly, and staff assist . Interviews with additional residents, reported that staff assist residents with showers if needed; while others are independent and do not need assistance. Therefore, the allegation "Facility staff are not assisting resident showering needs", is UNSUBSTANTIATED at this time.

Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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