197609621-6-2-2021-31-AS-NMAN-C6VN33-20210915100541

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 06/02/2021
Date Signed: 06/02/2021 02:46:25 PM

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
05/26/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210526162432

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: 109	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff pushed resident in care

INVESTIGATION FINDINGS:

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

At 10:00 AM, LPA conducted physical plant tour, reviewed facility records and requested copy of pertinent documents relevant to the investigation. At 10:25 AM, LPA interviewed staff, administrator and resident of the facility. At 11:00 AM, LPA conducted collateral visit to Post Acute Rehabilitation Center and interviewed Resident #1 (R1). LPA interview with R1 revealed that R1 was not pushed by the staff but was nudged only and could have been accidental that is why R1 did not report it. LPA interview with the administrator revealed that the administrator did not receive any report from any resident being pushed by any staff at the facility. Staff #1 (S1) denied pushing any resident during LPA's interview. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.
Exit interview conducted. Copy of this report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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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