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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 07/29/2021
Date Signed: 07/29/2021 04:22:08 PM

Unsubstantiated


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
07/23/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210723161912
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: 107DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Monique Lopez - AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff disposed of resident belongings.
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 9:15 AM. Requested copies of facility documents relevant to the investigation at 10:00 AM. Between 10:15 AM to 12:40 PM, conducted interview with the administrator, licensee and staff. Regarding the allegation that facility staff disposed of resident belongings, LPA record review at 10:00 AM, revealed that Resident #1 (R1) is self responsible and signed the admission agreement on 08/12/19 which includes the provision that in case of leaving the facility such as hospital or rehabilitation, "any belongings left behind the facility, and not removed by residents or legal guardian will be held for 21 days only then discarded". LPA interview with administrator revealed that the administrator called the case worker of R1 on 12/08/20 and 12/15/20 but did not pick up or sent a representative to pick up R1's belongings and it was only after thirty (30) days that R1's belongings were discarded. (continued)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (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)
Page: 1 of 3
Control Number 31-AS-20210723161912
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 on LIC 9099-C)

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (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)
Page: 2 of 3