197609621-10-19-2021-31-AS-NMAN-CDPQPV-20220421122121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 10/16/2021
Date Signed: 10/19/2021 08:41:22 AM

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 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:	08:35 AM
MET WITH:	Amourfino Cruz - Staff		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident social security checks are still coming to this facility even though resident has been gone for 6 months.

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 staff at 10:45 AM. Regarding the allegation that Resident's social security checks are still coming to this facility even though resident has been gone for 6 months. LPA's record review on 07/29/21 at around 10:30 AM and today at 11:30 AM, revealed that R1 left the facility on 11/26/2020 and SSA benefits payments were sent to the facility via direct deposit until May 2021. LPA's interview with the Licensee today at 12:05 PM, revealed that once a resident or any person has designate a payee, SSA do not change the payee until that resident or person designate another payee, hence, the continuation of payment to the facility despite formal notice to discontinue payment, which the facility did on 12/20/2020 through the SSA local office.
(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-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: 10/16/2021

NARRATIVE

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(continued from LIC 9099)

Further, LPA's interview with the Administrator today at 1:00 PM revealed that the she has been following up with Social Security Administration (SSA) office to send the overpayment bill to pay back the money to SSA, but has not received the bill to date. It is necessary to receive the bill in order to pay the exact amount to be refunded to SSA. Moreover, LPA's interview with the Licensee today at 12:05 PM also revealed that it is disadvantageous to the facility to get this payment as this will be considered as revenue and may be subject to tax, when in fact they have to return the money, so the facility had to close the bank account receiving the payment to avoid further payment to the facility.

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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