197609621-8-14-2021-31-AS-NMAN-C67VYF-20210824165104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 08/14/2021
Date Signed: 08/14/2021 03:53:10 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
10/09/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20201009110658

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:	08/14/2021
		UNANNOUNCED	TIME BEGAN:	10:52 AM
MET WITH:	Marilyn Nguyen - Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff failed to assist resident with wheel chair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with administrator Marilyn Nguyen and explained the reason for the visit.

LPA conducted physical plant tour at 11:05 AM. LPA requested facility documents relevant to the investigation at 11:40 AM and interviewed staff and residents between 12:00 Noon to 2:00 PM. LPA's interview with Resident #1 (R1)'s room mate at 1:30 PM today, revealed that R1 always get assistance transferring to and from R1's wheelchair from the staff all the time and that R1 called 911 whenever R1 requested to be attended by a particular staff that R1 liked but was not able to show up as the staff rotates all the time. LPA interview with the administrator on 10/13/2020 at 11:30 AM, revealed that R1 calls the office using own cell phone whenever R1 requests for staff assistance and never used the call button. R1 also called 911 through own cell phone. (continued on LIC 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: 08/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2021

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-20201009110658

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: 08/14/2021

NARRATIVE

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(continued from LIC 9099)

LPA's interview with staff at 1:20 PM today, also revealed that staff never refused any call for assistance from R1 but admitted that there are times that there are some delay during busy times of the day because care staff are also attending to other residents.

Based on the information gathered during this and prior visit, 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: 08/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2021

LIC9099 (FAS) - (06/04)

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