197609621-10-4-2023-31-AS-TAGD-CY7UU7-20231204145305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 06/20/2023
Date Signed: 10/04/2023 01:13:31 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
04/28/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230428114119

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: 118	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	08:43 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff injured resident while in care

Staff locked resident in room

INVESTIGATION FINDINGS:

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This report was amended to change the findings from unfounded to unsubstantiated.

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

LPA conducted physical plant tour at 9:20 AM, requested facility documents relevant to the investigation at 9:55 AM, conducted record review between 10:00 AM to 11:35 AM and interviewed the administrator and staff between 11:35 AM to PM to 1:00 PM. Regarding the allegation that the staff injured resident while in care, it was alleged that Staff "Maria" cut Resident #1 (R1)'s right under chest on 04/03/23 at 1:00 PM while in own bed. LPA's record review today between 10:00 AM to 11:35 AM of R1's exit documents and Unusual Incident report (LIC 624) revealed that R1 left the facility on 04/01/23 at around 11:00 AM, transported to a nearby hospital and did not come back to the facility since. (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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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-20230428114119

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: 06/20/2023

NARRATIVE

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(continued from LIC 9099)

LPA's interview with the administrator today at 11:50 AM revealed that R1 complained of leg pain that was why R1 was sent to the hospital. Further interview also revealed that there was no care staff named "Maria" working in the morning and/or afternoon shift and the only care staff named "Maria" is working only on graveyard shift.

Regarding the allegation that Staff locked resident in room, it was alleged that staff Maria locked R1 in own room on 04/03/23 at about 1:00 PM. LPA's record review today between 10:00 AM to 11:35 AM of facility's unusual incident report (LIC 624) revealed that R1 left the facility on 04/01/23 at around 11:00 AM, transported to a nearby hospital and did not come back to the facility since. LPA's interview with the administrator today at 11:50 AM revealed that R1 complained of leg pain that was why R1 was sent to the hospital. Further interview also revealed that there was no care staff named Maria is working in the morning or afternoon shift and the only care staff named "Maria" is working only on graveyard shift. LPA's observation today at 9:35 AM also revealed that R1's roommate when R1 was still at the facility is still living at the facility to date. LPA's interview with R1's roommate revealed that no staff had locked their room nor witnessed any staff harming R1 when R1 was still at the facility.

Based on the information gathered during this and prior 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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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