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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197609621
Report Date:
04/15/2022
Date Signed:
04/15/2022 08:25:52 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
04/14/2022
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20220414140807
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:
04/15/2022
UNANNOUNCED
TIME BEGAN:
10:40 AM
MET WITH:
Monique Lopez
TIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication errors
Food is not of good quality
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.
Medication Errors
It is alleged that resident # 1(R1) has not received their medication as they are supposed to. LPA reviewed R1's medication and medication record from 11-12pm. LPA obtained copies of R1's medication record for March up to today's date. LPA interviewed R1 regarding this allegation from 1-1:30pm. Information from interview and review of medication reveal that R1 has been receiving their medication as they are supposed to therefore 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:
04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/15/2022
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-20220414140807
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:
04/15/2022
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
Food is not of good quality
It is alleged that the food is not of good quality and that fruits and vegetables are not provided to residents. From 12pm-1pm LPA went to the dining room and observed lunch being served to residents and also checked the food supply. LPA also interviewed residents from 1-2pm regarding the food being provided by the facility. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time.
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:
04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/15/2022
LIC9099
(FAS) - (06/04)
Page:
2
of
2