197609621-9-20-2021-31-AS-NMAN-C9NSAV-20211213124257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 09/18/2021
Date Signed: 09/20/2021 11:48:33 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
05/05/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210505135153

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:	09/18/2021
		UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Marcelo Nogar - Staff		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident is being left soiled for extended periods of time while in care

Staff do not respond timely to a resident's requests

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 Marcelo Nogar and explained the reason for the visit.

LPA conducted physical plant tour at 9:00 AM. Requested and reviewed facility documents relevant to the investigation at 9:30 AM. LPA conducted interviews with staff and residents between 10:50 AM and 2:00 PM. Regarding the allegation that Resident is being left soiled for extended periods of time while in care, LPA's record review between 9:30 AM to 10:50 AM, revealed that Resident #1 (R1's) diapers are being changed regularly at least three (3) times a day and as needed. LPA's interview with R1 on 05/12/21 at 2:30 PM, also revealed that R1's diapers are being changed regularly. LPA's interview with three (3) care staff on 05/12/21 at 3:00 PM and today between10:50 AM to12:15 PM, confirmed that R1 is being changed at least twice on each shift, i.e., morning (6:00 AM to 2:30 PM) and afternoon (2:30 PM to 10:30 PM) shift and did not receive any report nor observed that R1 was left soiled for extended period of time. (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: 09/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2021

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-20210505135153

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: 09/18/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff do not respond timely to a resident's requests, LPA's interview with R1 on 05/12/21 at 2:30 PM, revealed that staff come to his room whenever R1 called for assistance but there are times that staff took a while before coming but did not exceed an hour. LPA's interview with three (3) care staff on 05/12/21 at 3:00 PM and today between 10:50 AM to12:15 PM revealed that when R1 called during meal time, all of the care staff are assisting other residents who need assistance on feeding which usually cause the delay for less than an hour but during normal routine hours, staff always within reasonable time. LPA's interview with ten (10) residents between 10:50 AM and 3:00 PM also revealed that the staff always come within reasonable time whenever they needed assistance.

Based on the information gathered during this and prior visit, the allegation is 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: 09/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2021

LIC9099 (FAS) - (06/04)

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