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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:48:22 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
11/12/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20211112090642
FACILITY NAME:GOLDEN ASSISTED LIVINGFACILITY NUMBER:
197609621
ADMINISTRATOR:LOPEZ, MONIQUEFACILITY TYPE:
740
ADDRESS:14060 ASTORIA STTELEPHONE:
(818) 367-1947
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:128CENSUS: 104DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marilyn NguyenTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Illegal Eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit. LPA was joined on the visit by Long Term Care Ombudsman (LTCO) Velvet Tabb.
LPA met with administrator Monique Lopez and licensee Marilyn Nguyen and explained the reason for this visit.
Regarding the allegation it is alleged that resident #1 (R1) was illegally evicted from the facility. LPA conducted a previous visit on 11/16/21 where LPA reviewed R1's facility file and obtained copies of pertinent information. During today's visit LPA conducted interviews with the administrator and licensee from 1:00-2:45 pm regarding the allegation. LPA had previously interviewed R1 over the telephone regarding this allegation. Information from interviews reveal that R1 went to the hospital on 10/27/21 due to not feeling well. Interviews reveal before going to the hospital and while at the hospital R1 was told they were not going to be able to come back to the facility. LPA was able to verify that staff from Department of Health Services was contacted and told that R1 was not allowed to come back to the facility and that new placement was needed for R1.
Based on the information obtained through interviews this allegation is deemed Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20211112090642
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: 12/03/2021
NARRATIVE
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Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/12/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20211112090642

FACILITY NAME:GOLDEN ASSISTED LIVINGFACILITY NUMBER:
197609621
ADMINISTRATOR:LOPEZ, MONIQUEFACILITY TYPE:
740
ADDRESS:14060 ASTORIA STTELEPHONE:
(818) 367-1947
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:128CENSUS: 104DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marilyn NguyenTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident personal belongings were missing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit. LPA was joined on the visit by Long Term Care Ombudsman (LTCO) Velvet Tabb.
LPA met with administrator Monique Lopez and licensee Marilyn Nguyen and explained the reason for this visit.

It is alleged that resident #1 (R1) personal belongings were missing such as baseball cards and coin collection when they came to pick up their belongings from the facility on 11/5/21. LPA interviewed facility staff and R1 regarding this allegation. LPA also reviewed R1's facility file which included R1's personal property list. The items listed on R1's personal property list did not include any baseball cards or coin collection. Based on the information obtained through interviews and file review this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20211112090642
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2021
Section Cited
CCR
87224(d)
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Eviction Procedures. The licensee shall state in the notice to quit the reasons for the eviction with specific facts about the date, place, witnesses and circumstances concerning those reasons. This requirement was not met as evidenced by:
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Administrator will submit statement that all residents will be provided proper eviction notices and all procedures will be followed throughout the eviction process based on Title 22 regulations and Health and Safety code regulations.
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Based on interviews conducted facility failed to provide R1 with a proper eviction notice and informed R1 and the hospital that R1 would not be welcome back to the facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4