197609621-6-9-2023-31-AS-TAGD-CX4SFD-20231030135010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:36:40 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
06/01/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230601140224

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: 120	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not kept clean

Staff did not ensure facility is kept free of pests

Facility is refusing to accept resident back to the facility

INVESTIGATION FINDINGS:

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

LPA conducted physical plant tour at 9:05 AM, requested copies of facility documents relevant to the investigation at 9:45 AM and interviewed staff and residents between 10:00 AM to 2:00 PM. Regarding the allegation that the facility is not kept clean, it was alleged that the restrooms are not kept clean. LPA's physical plant tour at 9:05 AM in ten (10) random residents' rooms on both floors revealed that the ten (10) out of ten (10) restrooms are generally clean. LPA's interview with the administrator at 10:00 AM revealed that they four (4) housekeepers during morning shift, two (2) housekeepers for each floor who cleans the residents bathroom on a daily basis. LPA's interview with twelve (12) residents or 10% of the current census revealed that all of the twelve (12) residents interviewed stated that housekeeping staff clean their restrooms everyday. (continued on 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: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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-20230601140224

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: 06/09/2023

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff did not ensure facility is kept free of pests, it was alleged that the facility is infested with cockroaches. LPA's record review today at 1:21 PM revealed that the facility has a contracted pest control company who visit every month to ensure that the facility is free of pests inside and outside. LPA's interview with twelve (12) residents or 10% of the current census between 10:00 AM to 2:00 PM also revealed that twelve (12) out of twelve (12) residents interviewed did not see or observed any cockroach in their room or anywhere in the facility.

Regarding the allegation that the Facility is refusing to accept resident back to the facility, it was alleged that the facility administrator did not want to accept Resident #1 (R1) to go back at the facility. LPA's record review today at 1:21 PM revealed that R1 is still at the Skilled Nursing Facility (SNF) in Van Nuys and still undergoing Occupational Therapy until 06/27/23. LPA's interview with the administrator today at 10:00 AM revealed that she did not refused nor evicted R1 but was communicating with the SNF and was informed that R1 was still undergoing therapy and not ready to be discharged. Further interview also revealed that the SNF had already contacted a six (6) beds Assisted Living Facility in Valley Glen to move R1 upon discharge and the Power of Attorney (POA) of R1 has already called the facility to pack R1's belongings at the facility for a later pick up.

Based on the information gathered during this visit, the allegations are 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: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

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