197609621-12-16-2021-31-AS-CHAS-CCF2U8-20220311164156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 12/12/2021
Date Signed: 12/16/2021 10:24:35 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
12/03/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20201203101436

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: 100	DATE:	12/12/2021
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Marilyn Nguyen - Licensee		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility is not meeting resident's care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegation. LPA met with Licensee Marilyn Nguyen and explained the reason for the visit.

It was alleged that Resident #1 (R1) was diagnosed with malnutrition and dehydration upon hospitalization on 12/01/2020 though R1’s condition could be a result of self-neglect.

On 12/04/2020 at 1:02 PM, LPA Tan initiated the complaint visit via virtual visit. At around 1:20 PM, LPA interviewed the administrator telephonically and requested copies of the facility records relevant to the investigation at around 2:00 PM.

(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: 12/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2021

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-20201203101436

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: 12/12/2021

NARRATIVE

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(continued from LIC 9099)

LPA’s record review on 08/21/21 at around 10:00 AM, revealed that R1 was admitted at the facility on 08/11/2020 with the medical diagnosis and medication therapy causing loss of appetite and dehydration. Further record review today between 9:00 AM to 10:30 AM also revealed that prior to admission, R1 had an ongoing underweight issue and was sent to the hospital by the staff while at the facility on 10/23/20 for failure to thrive. R1 was also on strict diet of limited intake due to R1's medical condition. Medication record review revealed that R1 was on vitamin supplements. LPA's interview with staff on 08/21/21 at around 10:00 AM and today between 10:30 AM to 12:00 PM revealed that the staff provided food supplement (i.e. Ensure) and a gallon of drinking water on R1's bedside for hydration. LPA's observation today at 1:24 PM, during physical plant tour confirmed that staff provided a gallon of drinking water to residents who need hydration. LPA’s interview with R1’s roommate on 08/21/21 at around 10:15 AM revealed that R1 barely eat own food and was so skinny since admission. LPA’s interview with the administrator on 12/04/20 at around 1:05 PM, also revealed that R1 was hospitalized on 12/01/20 due to low blood sugar and prior to hospitalization R1 was consuming only around 15% of food served.

R1's malnutrition and dehydration was caused mostly by R1's health problems that required appropriate care and supervision. Appropriate care and supervision was provided to R1 as required.

Based on information gathered during the course of the investigation, the allegation is deemed unsubstantiated at this time.

Exit interview conducted and 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: 12/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2021

LIC9099 (FAS) - (06/04)

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