197609621-9-15-2023-31-AS-TAGD-D7PLRE-20240731085900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 09/15/2023
Date Signed: 09/15/2023 01:41:59 PM

Substantiated

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
09/13/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230913160843

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:	09/15/2023
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff are not addressing a bio hazard on facility premises

INVESTIGATION FINDINGS:

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

LPAs conducted physical plant tour at 9:55 AM, requested copies of facility documents relevant to the investigation at 10:18 AM. It was alleged that several of the men who live at this facility urinate on the side of the wall on the outside grounds of the facility, LPAs observation during physical plant tour today at 9:55 AM, revealed that there was a faint smell of urine along the pathway on the side of the facility leading to the smoking patio of the outside yard. LPAs also observed some urine marking on the floor on the bicycle rack near the smoking patio. LPAs record review of photographic evidence also revealed that some of the residents are indeed urinating outside near the smoking patio area. Based on the information gathered during this visit, the allegation is deemed substantiated at this time. Exit interview conducted. Copy of this report issued.

Substantiated

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: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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-20230913160843

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/29/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to clean the area and put more lights, cctv and warning speaker so that night staff could warn the residents trying to urinate in the area and agreed to submit proof of correction on or before the POC date.
	8 9 10 11 12 13 14	Based on LPAs observation the licensee failed to ensure that the facility is clean, safe and sanitary at all times which poses a potential health and safety hazard to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

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