197609621-5-27-2023-31-AS-TAGD-CUBNFP-20230802102552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 05/27/2023
Date Signed: 05/27/2023 03:27:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
03/20/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230320154213

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: 114	DATE:	05/27/2023
		UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Amourfino Cruz - Staff		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff member is physically abusing resident(s) in care

Staff member is verbally abusing resident(s) 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 initial complaint visit at this facility to investigate the above allegations. LPA met with staff Amourfino Cruz and explained the reason for the visit.

LPA conducted physical plant tour at 9:15 AM, requested copy of facility documents relevant to the investigation at 9:42 AM and interviewed staff and residents between 10:00 AM to 2:10 PM. Regarding the allegation that Staff member is physically abusing resident(s) in care, it was alleged that a male staff member who is physically abusing residents and "fight" with a female resident. Resident #1 (R1) allegedly saw the staff hit this resident "3-4 times" and stated that other staff members saw and heard the incident as well. LPA's interview with R1 on 03/21/23 between 10:00 AM to 1:00 PM revealed that R1 did not actually see the "fight" but just heard it as it occurred just outside of R1's room. R1 also denied being hit by any staff. LPA's interview with staff closely resembling the description given by R1 and was on duty on 03/12/23 or the day of the incident, today between 10:00 AM to 2:10 PM, revealed that both of these staff denied hitting anyone on the day of the alleged incident or at anytime. (continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

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 2

Control Number 31-AS-20230320154213

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN ASSISTED LIVING	FACILITY NUMBER: 197609621
	VISIT DATE: 05/27/2023

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)

LPA's close circuit television (CCTV) review today at 1:35 PM also revealed that there was no incident of "fighting" or "yelling" on the date and time described by R1 outside of R1's room nor there is any incident "fighting" nearby R1's room.

Regarding the allegation that Staff member is verbally abusing resident(s) in care, it was alleged that R1 was verbally abused by the staff by threatening R1 that the Staff is going to "kill" him. LPA's interview with two (2) staff present on the day of the alleged incident revealed that no one threatened R1 nor they heard any other staff threatened R1. LPA's interview with Resident #2 (R2) today between 10:00 AM to 2:10 PM revealed that R2 did not see or hear any staff fighting with any resident at anytime nor witnessed any staff threatening to "kill" R1. LPA's interview with twelve (12) random residents or more than 10% of the current census today between 10:00 AM to 2:10 PM also revealed that ten (10) out of twelve (12) residents stated that the staff are respectful to them and twelve (12) out of twelve (12) residents did not experience being yelled at by any staff nor they witness any staff yelling or threatening anyone.

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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2