197609621-6-13-2021-31-AS-NMAN-C56VC9-20210722161845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 06/13/2021
Date Signed: 06/13/2021 06:22:52 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
03/17/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200317100657

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: 108	DATE:	06/13/2021
		UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Mark Rodriguez - Staff		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not administer medication as prescribed
Staff allowed resident's to use drugs in the facility
Staff do not treat residents with respect
Staff confiscated resident's personal belongings
Resident does not have access to phone

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with staff Mark and explained the reason for the visit.

LPA conducted physical plant tour at 9:02 AM. At 10:00 AM, LPA interviewed residents and staff of the facility. At 11:05 AM, LPA requested pertinent documents relevant to the investigation.

Regarding the allegation that staff did not administer medication as required, LPA record review revealed that Resident #1 (R1) is compliant with taking own's medication as prescribed, LPA interview with medication technician also revealed that R1 always take medication on time as prescribed. LPA interview with R1 confirmed that R1 takes own medication regularly as prescribed.

(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: 06/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2021

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-20200317100657

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: 06/13/2021

NARRATIVE

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(continued from LIC 9099)

Regarding allegation that Staff allowed residents to use drugs in the facility, LPA interview with eleven (11) (or 10% of the current census) random residents revealed that no one witnessed any other resident using drugs in the facility. LPA interview with R1 also revealed that R1 did not see any resident using drugs inside the facility.

Regarding the allegation that Staff do not treat residents with respect, LPA interview with eleven (11) (or 10% of the current census) random residents revealed that staff were respectful to them, and none of them reported any staff being rude or abusive to them. LPA interview with R1 also revealed that the staff are respectful and treat R1 well.

Regarding the allegation that Staff confiscated resident's personal belongings, LPA interview with R1 revealed no staff has confiscated any of R1's belongings.

Regarding the allegation that Resident does not have access to phone, LPA interview with R1 revealed that R1 has always access to facility telephone and R1 has own cell phone to use.

Based on the information gathered during this and prior visit, the allegations are all 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: 06/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2021

LIC9099 (FAS) - (06/04)

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