197609621-11-2-2021-31-AS-CHAS-C93VTS-20211124154336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:05:50 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
10/25/2021 and conducted by Evaluator Tuesday Cabiness

COMPLAINT CONTROL NUMBER: 31-AS-20211025160627

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:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Monique Lopez & Marilyn Nguyen		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility did not release resident's records to resident's responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit, pertaining to the allegation mentioned above. LPA met with Administrator Monique Lopez and Licensee Marilyn Nguyen; the following was determined:

Concerns were expressed that “Facility did not release resident’s records to resident’s responsible party”. On 11/02/2021, from 930am to 1215pm, LPA conducted interviews, and reviewed documentation pertaining to the complaint. According to the Administrator, on 10/22/2021, the facility received notification to provide medical records for resident # 1 (R1) to a legal service, who was to copy records. The Administrator reported to LPA, that she informed the legal service, that the facility did not receive the 1st request and to re-fax. On 10/25/2021, the Administrator contacted the legal service, and informed them, the records

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: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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-20211025160627

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: 11/02/2021

NARRATIVE

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were ready to be copied. On 10/28/2021, the copier service visited the facility and copied records. On 11/01/2021, the copier service contacted the Administrator and requested (2) documents to be re-faxed, due to not being led gable to read. The Administrator informed them; the documents will be ready on 11/02/2021. Based on documentation and interviews conducted, there is insufficient evidence to prove, the “Facility did not release resident’s records to resident’s responsible party”, therefore the allegation is deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

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