197609621-4-28-2023-31-AS-NMAN-CSCL5W-20230531082750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:30:37 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
08/15/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20220815124252

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: 124	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	12:14 PM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed multiple pressure injuries while in care
Resident sustained an unexplained stab wound while in care
Resident was assaulted while in care
Staff are not providing a safe environment for resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegations. LPA met with Administrator Monique Lopez and explained the reason for the visit.

Initial investigation visit was conducted by LPA Nicholas Reed on 08/16/2022. At the time of visit between 10:35 AM and 12:20 PM. LPA Reed conducted a physical plant tour and a records review. The case was later referred to the Investigation’s Branch (IB) and an investigation was continued by the IB Investigator Real. Between 09/22/2022 and 12/07/2022 IB investigator conducted interviews with Resident #1 (R1)'’s home health care providers, doctors, facility Administrator, staff, and residents and obtained medical records from R1’s hospitalization. Regarding the allegation “Resident developed multiple pressure injuries while in care”, it was alleged that R1 developed pressure injuries on their heel and coccyx while in care.

(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: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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-20220815124252

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: 04/28/2023

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

(continued from LIC 9099)

From staff interviews on 09/23/22 and 10/14/22, staff mentioned routine observation of R1 about every two hours. Staff #1 (S1) and Staff #2 (S2) did not notice any pressure injuries on R1 prior to 08/05/2022. From review of R1’s hospital records conducted on 01/25/2023 at 10:20 AM, R1 was seen in emergency department (ED) at approximately 8:30 PM on 08/05/2022. And was transferred to the hospital at 12:00 AM on 08/06/2022. Hospital staff observed R1’s pressure injuries, but a wound consultation was not performed until 4:41 PM on 08/08/2022. At that time, it was determined that R1 developed three (3) Unstageable pressure injuries. A review of medical records did not reveal any supporting information to determine that R1 had unstageable pressure injuries at the time of admission to ED. Based on interviews and record review, there is no sufficient information to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Resident sustained an unexplained stab wound while in care”, it was alleged that R1 was stabbed in the knee while under facility care. From medical record review, R1 was admitted to the hospital on the night of 08/05/2022 with “multiple penetrating wounds”. From interviews conducted on 09/23/22, 10/14/22, and 10/28/22, no residents or staff witnessed the incident. On the night of 08/05/2022, R1 was observed on the floor of their room with blood on their leg and head. A broken coffee cup was also seen on the ground. R1 did not reveal how the injury happened. Resident #2 (R2) was the roommate of R1, and R2 did not report any previous issues or altercations with R1. R2 initially denied any knowledge of R1’s injury. R2 later stated that R2 hit R1 with the coffee mug but did not disclose further details. R2’s interview was of low credibility due to inconsistencies in R2's statement. From interviews and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Resident was assaulted while in care”, it was alleged that R1 was stabbed by an unknown assailant at the facility. From record review, the facility submitted an incident report after the police investigation. The police report has yet to be released, though it was determined that the stab wounds were self-inflicted. From interviews on 09/23/22 and 10/14/22, staff and residents did not see or hear any altercations leading up to R1’s injury. Staff #2 (S2) stated R1’s roommate R2 was observed lying down and appeared to be asleep when R1 was injured. Based on record review and interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. (continued to 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: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20220815124252

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: 04/28/2023

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

(continued from LIC 9099-C)

Regarding the allegation “Staff are not providing a safe environment for resident in care”, it was alleged that R1 was unsafe at the facility”. From interviews 09/23/22 and 10/14/22, residents expressed no safety concerns and felt treated well by staff. Staff described their frequent observation of residents about every two hours. Staff had not observed any signs of danger or unsafe situations. R1 and roommate R2 maintained a good relationship. From file review conducted on 01/25/2023 at approximately 10:45 AM, the facility did not have a history which indicated a lack of safety. Based on interviews and file review, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3