197609621-6-8-2021-31-AS-NMAN-CJ8U84-20220913152052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 06/08/2021
Date Signed: 06/08/2021 04:08:02 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
06/02/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210602091923

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: 110	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	12:11 PM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident exposed to harmful chemicals

Resident sustained food poisoning while eating food prepared by facility

Facility did not safeguard residents personal property.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan and Alex Pitz conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with administrator Monique Lopez and explained the reason for the visit.

At 12:45 PM, LPAs conducted physical plant tour. At 1:05 PM, LPAs requested additional facility documents relevant to the investigation. At 1:30 PM, LPAs interviewed administrator, staff and resident of the facility. Regarding the allegation that the resident is exposed to harmful chemicals, LPA interview with eleven (11) residents revealed that the housekeepers do not use any insecticide when cleaning their room. LPA interview with four (4) housekeepers confirmed that no one among them use any insecticide when cleaning the residents' room. LPA record review also revealed that the facility has a pest control company that visit monthly to avoid infestation at the facility.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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-20210602091923

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: 06/08/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Resident sustained food poisoning while eating food prepared by facility, LPA interview with Resident #1 (R1) revealed that R1 was unable to provide any detail as to when and what R1 ate at the facility when R1 had an alleged food poisoning. LPA interview with the administrator and staff also revealed that there was no report of any resident having a food poisoning at the facility for the last two (2) years. Further, LPA medical record review of R1 also revealed that there was no indication that R1 had ever a food poisoning during R1's stay at the facility.

Regarding the allegation that Facility did not safeguard residents personal property, LPA interview with R1 revealed that R1 was not able to provide any detail of any missing item R1 allegedly lost at the facility. LPA interview with the administrator also revealed that R1 did not report any missing item to the facility that could trigger for them to file a police report or investigate.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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