197609621-11-10-2021-31-AS-NMAN-CJ8U83-20220913152051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 11/06/2021
Date Signed: 11/10/2021 12:42:24 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: 106	DATE:	11/06/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Amourfino Cruz - Staff		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff refused to call 911 for resident.
Staff failed to observe changes in resident's condition
Facility retaliates against resident for filing complaints
Facility staff discriminate against resident
Facility is withholding mail

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with staff Amourfino Cruz and explained the reason for the visit.

LPA conducted physical plant tour at 8:50 AM. At 9:30 AM, LPA requested facility documents relevant to the investigation and between 10:30 AM to 1:00 PM, LPA conducted interview with staff and residents. Regarding the allegation that Facility staff refused to call 911 for resident, it was alleged that Resident #1 (R1) was so sick and was lying in a pool of own vomit and one of male staff from the office (name not provided) happened to see R1 and asked the staff to call 911 but staff said they don't call 911. LPA's interview with R1 on 06/08/2021 at around 3:43 PM revealed that R1 was not able to identify the facility staff who was asked to call 911. LPA's interview with Staff #1 (S1) today at 12:38 PM however, revealed that sometime in 2019, S1 found R1 lying on the floor of the basement near the vending machine with own vomit reeking of alcohol. S1 called 911 and R1 was picked up by the paramedics. S1 denied having asked by R1 to call 911. (continued on 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: 11/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2021

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 3

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: 11/06/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff failed to observe changes in resident's condition, it was alleged that despite a note from R1's doctors about R1's weight loss since living at the facility, the facility did not provide double portion of meals to R1. LPA's interview with R1 on 06/08/2021 at around 3:43 PM, revealed that R1 failed to provide any note from the doctor about providing double portion of meals LPA's record review today between 9:30 AM to 10:30 AM, revealed that there was no doctor's note on R1's file stating the same.

Regarding the allegation that Facility retaliates against resident for filing complaints, it was alleged that upon R1's return from the hospital, R1 was served eviction notice. LPA's interview with Resident #1 (R1) on 07/29/21 at around 2:00 PM and attempted interview today at 11:45 AM revealed that R1 was not aware that the source of complaint and/or complainant against any facility under Community Care Licensing (CCL) is strictly confidential and was never divulged to the facility and/or staff so that the facility could not retaliate nor take action against the complainant (be it resident/staff or any person who has an association with staff/resident of the facility). LPA's record review today between 9:30 AM to 10:30 AM revealed that R1 was being evicted for non-payment of R1's portion of rent to stay at the facility. Further review also revealed that R1 has not paid portion of R1's rent for more than two (2) years amounting to an approximate total of $23,284.41 to date.

Regarding the allegation that Facility staff discriminate against resident, it was alleged that some of the staff make grocery runs for the residents for a little cash but that the staff were told by management “Do not go to the store for R1" LPA's interview with R1 on 06/08/2021 at around 3:43 PM revealed that R1 was not able to identify the staff who told R1 that the management did not allow the staff to go to store for R1. LPA's interview with four (4) staff today revealed that there was only one (1) staff who used to run errands for the residents and that staff no longer works for the facility. Further, said staff only do the errands after own shift and at the staff's own discretion. Moreover, no staff is allowed to run errands for any resident during their shift.

(continued on LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 11/06/2021

NARRATIVE

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(continued from LIC 9099-C)

Regarding the allegation that the Facility is withholding mail. It was alleged that the staff are either throwing R1's mail out or returning it to sender. LPA's interview with the licensee and administrator on 06/03/2021 between 11:00 AM to 3:00 PM, revealed that no one is withholding mail for any resident nor there is anyone throwing away mail for the resident and the facility only sent back mail to sender when the resident no longer reside at the facility. LPA observation on 06/03/21 at 9:53 AM revealed that the facility has an incoming and outgoing mail box and R1 has mail in the incoming box. LPA's interview with staff today between 10:30 AM to 1:00 PM revealed that residents usually get their own mail everyday and if unclaimed for a number of days, whenever the resident get their medication, staff gave their mail too. LPA's interview with eleven (11) residents or 10% of the current census on 06/08/2021 between 1:30 PM to 3:30 PM revealed that eleven (11) out of eleven (11) residents get their mail regularly.

Based on the information gathered during this and prior visits the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this 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: 11/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2021

LIC9099 (FAS) - (06/04)

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