197609621-10-19-2021-31-AS-MVAO-CD9VF2-20220407162313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 10/16/2021
Date Signed: 10/19/2021 08:15:34 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
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:	10/16/2021
		UNANNOUNCED	TIME BEGAN:	01:31 PM
MET WITH:	Amourfino Cruz - Staff		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff seeking retribution for resident calling in complaints

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 allegation. LPA met with staff Amourfino Cruz and explained the reason for the visit.

LPA conducted physical plant tour at 9:45 AM, requested facility records relevant to the investigation at 10:13 AM and interviewed resident at 1:45 PM. It was alleged that the facility is seeking retribution for resident calling in complaints. LPA's interview with Resident #1 (R1) on 07/29/21 at around 2:00 PM, attempted interview today at 1:45 PM and attempted interview by LPA Lacy on 10/12/21 at around 1:15 PM revealed that R1 was not aware that the source of complaint and/or complainant against any facility under Community Care Licensing (CCL) is strictly confidential and was never divulged to the facility and/or staff so that the facility could not retaliate nor take action against the complainant (be it resident/staff or any person who has an association with staff/resident of the facility). Further, R1 could not identify any specific action by the facility that could be deemed retaliatory against the complainant except the eviction notice issued to R1. (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: 10/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2021

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: 10/16/2021

NARRATIVE

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(continued from LIC 9099)

LPA's record review today at 1:55 PM, revealed that R1 was served eviction notice for non-payment for over a year now. LPA's interview with the administrator today at 2:30 PM also revealed that R1 went to Unlawful Detainer process and the Court had evicted R1 but not until January of next year or if R1 found a suitable living arrangement prior to the eviction date.

Based on the information gathered during this and prior visit. 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: 10/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2021

LIC9099 (FAS) - (06/04)

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