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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609621
Report Date: 08/26/2022
Date Signed: 08/26/2022 02:56:31 PM


Document Has Been Signed on 08/26/2022 02:56 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: 113DATE:
08/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Marilyn Nguyen - LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to interview additional residents and staff regarding returned complaint dated 07/08/21 (cc no.: 31-AS-20210708160740). LPA met with licensee Marilyn Nguyen and administrator Monique Lopez and explained the reason for the visit.

At 9:00 AM, LPA conducted physical plant tour, requested copy of facility documents relevant to the investigation at 10:30 AM, and interviewed residents and staff between 10:40 AM to 2:00 PM.

There is no health and safety issue observed during this visit.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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