197609621-2-9-2022-31-AS-NMAN-CBHTB8-20220210133443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 01/08/2022
Date Signed: 02/09/2022 02:24:02 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
04/30/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200430135701

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: 112	DATE:	01/08/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Marilyn Nguyen - Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff is not obtaining medical care for resident in a timely manner

INVESTIGATION FINDINGS:

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This is an amendment of the report issued on 07/29/2020 to add more information.

Licensing Program Analyst (LPA) Gary Tan conducted a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Monique Lopez. It was alleged that the facility staff did not deal with resident medical issue.

LPA conducted virtual physical plant tour at 1:30 PM, requested relevant facility records at 2:20 PM and conducted interview with administrator, staff and attempted interview with resident of the facility between 2:20 PM to 3:00 PM. LPA record review of medical record of Resident #1 (R1) on 07/29/20 and today at 2:30 PM, revealed that R1 had no medical condition that required immediate medical attention. LPA's interview with R1 today at 12:30 PM confirmed that R1 had no medical emergency at the time of this complaint but had emergency sometime in February 2020 which the staff sent R1 to the hospital. (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: 01/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2022

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-20200430135701

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: 01/08/2022

NARRATIVE

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(continued from LIC 9099)

LPA interview with the staff on 07/29/20 at 2:01 PM, and today with the licensee and staff between 1:00 PM to 3:00 PM also revealed that R1 never complained of any medical condition that may require immediate medical attention. Moreover, LPA's record review today at 2:30 PM also revealed that R1 had an emergency on 02/24/20 with trouble breathing and choking and was sent to the hospital the same day. Based on the information gathered during the course of the investigation, 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: 01/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2022

LIC9099 (FAS) - (06/04)

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