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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 07/26/2022
Date Signed: 07/26/2022 03:16:51 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
07/25/2022 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220725142356
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
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Monique Lopez & Marilyn NguyenTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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1. Resident was inappropriately touched by another resident
2. Facility is not allowing visitor's resident's rooms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit, pertaining to the allegations mentioned above. LPA met with Administrator Monique Lopez and Licensee Marilyn Nguyen, who was informed the reason of the visit, the following was determined:

Allegation # 1: Resident was inappropriately touched by another resident. On July 26, 2022, from 8am to 1130am, LPA reviewed the complaint and documents, as well as, conducted interviews. From 12pm to 3pm, while at the facility, LPA conducted additional interviews and conducted a physical plant inspection. It was alleged, that resident # 1 (R1) was inappropriately touched by another resident. Through information obtained, there was an incident between R1 and another resident; but there were no witnesses, and R1 did not inform facility staff. R1 handled the situation, and the other resident was put on notice about the inappropriate behavior. R1 informed the other resident, that if the incident occurred again, facility staff would be notified. R1 reported, there has not been any other issues since then and the other resident has apologized to R1. Therefore, since R1 has addressed the issue, without staff interference, and based on interviews, the allegation
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20220725142356
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: 07/26/2022
NARRATIVE
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is UNSUBSTANTIATED at this time.

Allegation # 2: Facility is not allowing visitation in resident’s rooms. On July 26, 2022, from 8am to 1130am, LPA reviewed the complaint and documents, as well as, conducted interviews. From 12pm to 3pm, while at the facility, LPA conducted additional interviews and conducted a physical plant inspection. It was alleged that facility staff are not allowing visitation in resident’s rooms. Through the information obtained, it was reported to LPA that the facility does allow visitors in resident’s rooms, but prefers that visitation is conducted in spacious areas, such as the outside patio, or lobby. Residents did report to LPA that some visitation was not allowed, but mainly due to the facility’s COVID-19 policy. The facility has made exceptions, and family or friends have been allowed in their rooms. Although, recently it was alleged, the facility was not allowing visitors in resident’s rooms, it was reported to LPA, that if the resident and roommate agree and consent to the visitor being in the room, then it is allowed. Therefore, based interviews, the allegation is UNSUBSTANTIATED at this time.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/25/2022 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220725142356

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
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Monique Lopez & Marilyn NguyenTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit, pertaining to the allegations mentioned above. LPA met with Administrator Monique Lopez and Licensee Marilyn Nguyen, who was informed the reason of the visit, the following was determined:

Allegation # 1: Facility is in disrepair. On July 26, 2022, from 8am to 1130am, LPA reviewed the complaint and documents, as well as, conducted interviews. From 12pm to 330pm, while at the facility, LPA conducted additional interviews and conducted a physical plant inspection. LPA observed in resident’s (R1) room to be dirty, and had filthy walls, floors, and closet doors. Walls also had dried liquid stains. There was a large slab of flooring missing, and the wall, located outside of the bathroom, had an opening exposing wires and pipes. LPA also observed torn curtains. It was revealed to LPA, that both residents in the room was admitted with the condition it was observed during today’s physical plant inspection. This is a potential health and safety risk to residents in care.
Exit interview conducted, appeal rights, and copy of report provided.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220725142356
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: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety...This
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Administrator and Licensee will submit corrected repairs, with photos by POC date. If more time is needed, contact LPA.
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requirement was not met, evidenced by, based on physical plant inspection, room # 103, had dirty and stained walls, dirty floors, missing flooring and exposed pipes and wires. This is a potential health and safety risk to residents in care.
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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
LIC9099 (FAS) - (06/04)
Page: 4 of 4