<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609621
Report Date: 07/26/2022
Date Signed: 07/26/2022 03:22:02 PM


Document Has Been Signed on 07/26/2022 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197609621
ADMINISTRATOR:LOPEZ, MONIQUEFACILITY TYPE:
740
ADDRESS:14060 ASTORIA STTELEPHONE:
(818) 367-1947
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:128CENSUS: 115DATE:
07/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Monique Lopez & Marilyn TIME COMPLETED:
03:30 PM
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
Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management, in conjunction to complaint control # (31-AS-20220725142356). During the investigation, it was reported to LPA that resident # 1 (R1) personal items were stolen, and returned to R1. Upon further information, once the items were returned, they were then re-stolen, and returned back to R1. The only item that was not returned was a scale. The incident was not reported to Licensing, and LPA did not receive a special incident report (SIR). The Administrator informed LPA during the visit, that R1 was reimbursed for the scale that was stolen, and LPA received a SIR at the conclusion of the visit. Therefore, a citation was issued today, for failure to report, and plan of correction (POC) was submitted. This is a potential health and safety risk to residents in care.


Exit interview, copy of report, appeals, and report was provided.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/26/2022 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2022
Section Cited

1
2
3
4
5
6
7
Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing...within seven days of the occurrence of any events specified in
8
9
10
11
12
13
14
(A0 through (D)...This requirement was not met, evidenced by, based on information obtained during today's visit, items were stolen from a resident and facility did not submit an incident report.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2