197609621-12-8-2022-31-AS-MVAO-CMXQSB-20230110112514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:32:15 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
11/30/2022 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20221130143933

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: 115	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Monique Lopez		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility staff served resident food with a screw in it.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Monique Lopez and informed her the purpose of the visit. The following was determined:

From 10am to 1230pm, LPA conducted interviews and reviewed documentation pertaining to the allegation mentioned above. From information obtained, it was determined, that there were no witnesses to corroborate the allegation "Facility staff served resident with screw in it". LPA conducted interviews with numerous residents, including the interested parties involved with the complaint, and reviewed the photo of the screw, but LPA could not find sufficient evidence, the screw was in the food, on the alleged date. Also, it was revealed, staff were not notified until days after, and there were no complaints about the food on the alleged date to staff or the cook. Based on interviews and documentation reviewed, LPA could not find sufficient evidence to prove the allegation, therefore it is UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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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