197609621-4-19-2022-31-AS-CHAS-CDQRU3-20220422131917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:30:07 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
04/18/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220418153904

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: 103	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Monique Lopez		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was left on the floor unattended for an unknown period of time.

Resident was not supervised properly.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with the administrator and explained the reason for this visit.

Resident was left on the floor unattended for an unknown period of time.
It is alleged that on 4/17/22 when resident #1 (R1) family came to visit them that R1 was laying on the floor unattended for an unknown period of time. LPA conducted interviews with the administrator, R1's family member, and facility staff from 10-11am regarding this allegation. LPA reviewed R1's facility file and obtained copies of pertinent information from 11-12pm. Information from interviews reveal that when R1's family came to visit them they were laying down on the couch in the lobby sleeping. R1 was not laying on the floor and was not unsupervised at that time. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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 2

Control Number 31-AS-20220418153904

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: 04/19/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident was not supervised properly.
It is alleged that R1 was not supervised properly resulting in R1 being hospitalized. LPA conducted interviews with the administrator, R1's family member, and facility staff from 10-11am regarding this allegation. LPA reviewed R1's facility file and obtained copies of pertinent information from 11-12pm. Interviews revealed that on the night of 4/16/22 R1 had a hard time sleeping. On 4/17/22 when R1's family came to see them they were sleeping on the couch in the facility lobby and upon waking up did not feel well. Staff checked on R1 and a decision was made to call emergency services and R1 was transferred to the hospital. A review of R1's needs and service plan reveal that R1 is ambulatory and can do all their activities of daily living independently. Interview with R1's family revealed that R1 is still hospitalized and will be discharged back to the facility later this week. LPA reviewed R1's medication documentation and spoke with the nurse that came saw R1 that morning. Based on the information obtained through interviews and documentation reviewed this allegation is deemed Unsubstantiated at this time. There is not enough information to state that facility failed to properly supervise R1 causing R1 to be hospitalized. Exit interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2