197609621-12-5-2021-31-AS-NMAN-CDXP7J-20220429110400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 12/04/2021
Date Signed: 12/05/2021 01:28:10 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
04/15/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210415121055

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: 104	DATE:	12/04/2021
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Amourfino Cruz - Staff		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not seek medical attention in a timely manner

Facility staff do not ensure that resident has access to food

Facility staff are not assisting resident with ADLs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with staff Amourfino Cruz and explained the reason for the visit.

LPA conducted physical plant tour at 9:00 AM, requested copies of facility documents relevant to the investigation at 9:35 AM and conducted interview with staff and residents between 10:00 AM to 12:30 PM. Regarding the allegation that Facility staff did not seek medical attention in a timely manner, it was alleged that Resident #1 (R1) has an open sore wound for two (2) weeks. LPA's record review today at 12:35 PM, revealed that a facility visiting nurse provide wound treatment to R1 everyday from 03/25/21. R1 however, refused treatment on 03/27/21 and 03/29/21 and was hospitalized on 03/31/21. Further review also revealed that R1 was capable of self care and refused all hospital/doctor visit prior to 03/31/21.

(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: 12/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2021

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-20210415121055

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: 12/04/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that the Facility staff do not ensure that resident has access to food, it was alleged that no staff is bringing food to R1's room. LPA's record review today at 12:30 PM, revealed that R1 was ambulatory and has the capability of self care including but not limited to feeding, dressing/grooming, toileting and bathing. Moreover, LPA's interview with staff on 04/16/21 between 10:00 AM to 12:00 PM and today at 12:15 PM, revealed that R1 was provided trays upon request based upon R1's condition but not on a regular basis because R1 was capable of self care and regularly went out to buy own stuff.

Regarding the allegation that Facility staff are not assisting resident with ADLs, it was alleged that R1 took an hour to get dressed prior to a medical appointment. LPA's record review today at 12:30 PM revealed that R1 was capable of self care and did not need any assistance with ADLs. LPA's interview with six (6) staff on 04/16/21 between 10:00 AM to 12:00 PM and today at 12:15 PM, revealed that R1 was independent and was able to capable of self care.

Based on the information gathered during this and prior 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: 12/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2021

LIC9099 (FAS) - (06/04)

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