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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 06/08/2021
Date Signed: 06/08/2021 03:23:11 PM



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
10/17/2019 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20191017144836
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: 110DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marilyn NguyenTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to provide a safe living environment
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pitz conducted a tele-visit on this day for the purpose of delivering findings for the Investigations Branch (IB). Today's complaint investigation was conducted with Licensee Marily Nguyen.

On 10/21/20, LPA Pitz conducted an initial 10-day complaint visit. During the initial visit, LPA collected documents and interviewed Licensee. This allegation was referred to the Investigations Branch (IB) and was assigned to Investigator Douglas Real. IB investigator interviewed the facility administrator on 11/19/19, alleged victim on 1/13/20, one of the alleged perpetrators and a Los Angeles Police Department (LAPD) Detective on 2/3/20, four other witnesses on 1/17/20. Investigator also reviewed records from the facility, Holy Cross Medical Center, and LAPD.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
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)
Page: 1 of 5
Control Number 31-AS-20191017144836
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
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
Based on interviews and records reviewed, allegation #1, that “Facility failed to provide a safe living environment,” has been substantiated. Facility incident reports indicate that Resident 1 (R1) and Resident 2 (R2) had a repeated history of violence while living at the facility, which ultimately resulted in the incident on 9/14/19 where Resident 3 (R3) was stabbed three times. R1 was then allowed to return to the facility after being arrested and remained there from 09/17/19 to 10/26/19 without being given an eviction notice and without being re-appraised until R1 was re-arrested. During the time when R1 returned to the facility, police responded to another verbal altercation between R1 and R3.

Report reviewed and delivered. Exit interview conducted, deficiency on 9099D page. A signed hard copy will be returned to LPA via email and kept in the facility's file.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
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)
Page: 2 of 5
Control Number 31-AS-20191017144836
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited
CCR
87648.1(a)(2)
1
2
3
4
5
6
7
87468.1(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will submit a signed statement of understanding and intent to abide by the cited regulation, including a plan to train staff on what types of incidents and behaviors warrant reappraisal.
8
9
10
11
12
13
14
Based on interviews and record review, the facility did not ensure that safe living accommodations were provided when it allowed R1 and R2 to continuing residing at the facility without being reappraised after being involved in numerous violent encounters, which posed an immediate danger to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/17/2019 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20191017144836

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: 110DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marilyn NguyenTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision lead to client injury
Facility failed to report an incident
Facility is falsifying records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegations.


On 10/21/20, LPA Pitz conducted an initial 10-day complaint visit. During the initial visit, LPA collected documents and interviewed Licensee. This allegation was referred to the Investigations Branch (IB) and was assigned to Investigator Douglas Real. IB investigator interviewed the facility administrator on 11/19/19, alleged victim on 1/13/20, one of the alleged perpetrators and a Los Angeles Police Department (LAPD) Detective on 2/3/20, four other witnesses on 1/17/20. Investigator also reviewed records from the facility, Holy Cross Medical Center, and LAPD. On 6/8/21 LPA interviewed three additional staff members.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
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)
Page: 4 of 5
Control Number 31-AS-20191017144836
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
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
Allegation #1, that "Lack of supervision lead to client injury" has been unsubstantiated based on the client and staff interviews conducted by the Investigations Branch. All staff/ client interviews conducted indicated that the client injury could not have been prevented in the moment with additional supervision.

Allegation #2, that "Facility failed to report an incident," has been unsubstantiated based on a review of the facility's incident report folder. LPA confirmed that this incident was reported to the Regional Office on 9/14/19.

Allegation #3, that "Facility is falsifying records" has been unsubstantiated based on the records reviewed and the interviews conducted. 4/5 staff interviewed denied that any electronic footage had been deleted and that they were even able to do this, LPA was unable to review the footage of the time period in question, and LPA did not observe any means of deleting segments of footage from the facility's electronic surveillance system.

Report reviewed and delivered. Exit interview conducted, no deficiencies cited. A signed hard copy of this report will be obtained via email and kept in the facility's file.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
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)
Page: 5 of 5