197609621-4-11-2023-31-AS-TAGD-CX4NSJ-20231030104311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:14:00 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
04/03/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230403165141

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: 125	DATE:	04/11/2023
		UNANNOUNCED	TIME BEGAN:	11:48 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff member tampered with resident's medications causing them to feel ill.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan and Mariana Agban conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPAs met with administrator Monique Lopez and explained the reason for the visit.

LPAs conducted physical plant tour at 12:06 PM, requested copy of facility documents relevant to the investigation at 12:30 PM and interviewed staff between 12:45 to 2:00. It was alleged that Resident #1 (R1) would see Staff #1 (S1) spray something onto R1's medication that would make R1 dizzy and give R1 a stomachache, LPAs' observation during physical plant tour revealed that all of residents' medications are in bubble pack and when the medication technician prepares the medication for each resident, medications were place in a small brown envelope individually for distribution to all residents. LPAs' record review today between 2:00 PM to 2:30 PM also revealed that R1 has a diagnosis of Gastroesophageal reflux disease (GERD) and Dizziness from the time of admission on 12/13/21, moreover, R1 left the facility on 03/24/23 to spend a week on a friend's house but wasn't able to return as R1 was brought to the hospital directly from R1's friend's house.

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: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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-20230403165141

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: 04/11/2023

NARRATIVE

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(continued from LIC 9099)

R1 brought all medications including PRN medication when R1 left the facility on 03/24/23 LPAs interview with S1 revealed that R1's medication are all in bubble pack and denied spraying or putting anything on R1's medication as they prepare all medications all at once immediately before distribution. LPA interview with another medication technician confirmed that no one spray anything on anyone's medication as they have no reason to as they want to make the residents better, not worse. Also, when they prepare the medication, no other person is present nor the door is open at the medication room aside from the medication technician preparing the medication.

Based on the information gathered during this 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: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

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