197609621-12-12-2021-31-AS-NMAN-CDXP7H-20220429110359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 12/12/2021
Date Signed: 12/12/2021 03:27:34 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: 100	DATE:	12/12/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Marilyn Nguyen - Licensee		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident developed a pressure injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegation. LPA met with Licensee Marilyn Nguyen and explained the reason for the visit.

It was alleged that while in the facility, for the last couple of weeks, Resident #1 (R1) had an infected open sore.

The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to the IB investigator Laura Garcia.

The investigation of the allegation was initiated on 04/16/2021 at 9:07 AM, by LPA Tan and completed by the IB investigator Garcia.

(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: 12/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2021

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: 12/12/2021

NARRATIVE

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(continued from LIC 9099)

On 04/16/21 LPA conducted physical plant tour at 9:45 AM, interviewed residents, staff and administrator at 10:30 AM and obtained copies of the facility records relevant to the investigation at around 12:00 PM.

During subsequent investigation, Investigator Garcia interviewed staff, administrator and residents on multiple occasion. In addition, Investigator Garcia requested and reviewed medical records of R1’s recent hospitalization on 03/31/21,

LPA’s interview with R1 on 04/16/21 at 9:45 AM revealed that R1 was not aware as to the cause or origin of R1’s shoulder wound and expressed suspicion that it could have been caused by an insect bite.

Investigator Garcia’s interview with R1 on 04/21/21 at approximately 12:00 PM, revealed that R1 is independent and capable of self-care. R1 had a boil/cyst on left shoulder, which was already healed. R1 did not report to the staff about the wound on their shoulder as it would heal on its own.

Investigator Garcia’s interview with three (3) staff on 08/17/21 between 12:30 PM to 5:50 PM also confirmed the information received from R1.

Investigator Garcia’s medical record review, conducted on 05/26/21, revealed that R1 was diagnosed with “cellulitis” and there was no diagnosis of pressure injury.

Based on the information gathered during the course of the investigation, there is no relevant information to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted and 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: 12/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2021

LIC9099 (FAS) - (06/04)

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