197609621-7-29-2021-31-AS-MVAO-CD9VF3-20220407162313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 07/29/2021
Date Signed: 07/29/2021 04:25:16 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
07/26/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210726153616

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: 107	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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There is no hot water in residents room

The drain outside where buckets of dirty water are poured is plugged and running over

Staff are not providing adequate supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit to this facility to investigated the above allegations. LPA met with administrator Monique Lopez and explained the reason for the visit.

LPA conducted physical plant tour at 1:35 PM. Requested copies of facility documents relevant to the investigation at 2:00 PM. Between 2:00 PM to 4:00 PM, conducted interview with the administrator, staff and residents of the facility. Regarding the allegation that there is no hot water on the facility, LPA observation during physical plant tour revealed that the temperature of hot water in Resident #1 (R1)'s room was measured at 117.9°F. LPA also checked the water temperature on the entire wing where R1's room was located. A total of eight (8) rooms were checked and the hot water was measured at a range of 113.1°F to 119.6°F

(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: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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-20210726153616

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: 07/29/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that the drain outside where buckets of dirty water are poured is plugged and running over. LPA observation during physical plant tour at 1:35 PM, revealed that there was no drain existing just outside the facility near the kitchen, the water visible are water from the kitchen whenever they scrubbed the floor once a day in the afternoon and would easily dry out.

Regarding the allegation that staff are not providing adequate supervision, LPA interview with R1 at 2:00 PM revealed that R1 was not punched in the face but in the back, LPA interview with Resident #2 (R2) at 3:00 PM, however, revealed that R2 did not possess any knife and denied even touching R1. Further, it was R1 who went off on R2 and cussed R2 when R1 opened the door when R2 knocked on the door because R2 left own room key inside the room. LPA record review revealed that there was no Police/911 call or visit on the the day that R2 allegedly punched R1.

Based on the information gathered during this visit, the allegations are 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: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

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