197609621-2-21-2023-31-AS-TAGD-CX4PBD-20231030111008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 02/21/2023
Date Signed: 02/21/2023 02:28:07 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
02/17/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230217124055

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: 121	DATE:	02/21/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff left resident soiled for an extended period of time

Staff does not ensure resident is fed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial 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 9:15 AM, requested copy of facility documents relevant to the investigation at 10:00 AM and interviewed staff and residents between 10:30 AM to 1:00 PM.

Regarding the allegation that staff left resident soiled for an extended period of time, it was alleged that Resident #1 (R1) was left with soiled diapers, LPA's record review at 10:16 AM revealed that R1 did not have bowel or bladder impairment and did not require assistance in dressing/grooming, toileting and bathing. LPA's interview with three (3) caregivers today between 10:30 AM to 1:00 PM, who attended to R1 while staying at the facility revealed that none of them was asked by R1 for assistance on toileting and/or change R1's diapers. All three staff (3) stated that R1 did not use diaper. (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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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-20230217124055

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: 02/21/2023

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff does not ensure resident is fed, it was alleged that R1 was hungry, LPA's record review today between 10:00 AM to 10:30 AM revealed that R1 was given a tray service by a staff at 12:12 PM on the day that R1 was picked up by R1's family members. LPA's interview with three (3) caregivers today also revealed that while R1 was on the facility, R1 ate so little but being supplemented with Ensure every meal. LPA's interview with Resident #2 (R2) today at 12:35 PM, who was the room mate of R1 confirmed that R1 was able to go to the bathroom without any assistance, barely eat and was served tray during R1's less than five (5) days stay at the facility.

Based on the information gathered during this visit, the above allegations are 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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

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