197609621-1-26-2024-31-AS-TAGD-D83SWN-20240812141436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:45:08 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
08/17/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230817165539

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: 112	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for a resident

Staff did not ensure resident was adequately fed

INVESTIGATION FINDINGS:

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

LPA conducted physical plant tour at 9:02 AM, requested copy of additional facility documents relevant to the investigation at 9:34 AM, reviewed records from 10:00 AM to 11:30 AM and interviewed residents and staff between 11:30 AM to 1:15 PM. Regarding the allegation that Staff did not seek timely medical attention for a resident, it was alleged that Resident #1 (R1)'s catheter had been in that condition for approximately two weeks prior and no action was taken by facility staff. LPA's record review on 08/18/23 at 1:30 PM and today at 10:00 AM revealed that the facility contracted Licensed Vocational Nurse (LVN) had visited R1 on a daily basis and check on R1's catheter including but not limited to irrigation, checking the bag and tubing and emptying and/or replacement of catheter. Further, the nurse last visited R1 on 08/13/23 and was the one who recommended R1 to be brought to the hospital on the same day. (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: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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-20230817165539

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: 01/26/2024

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff did not ensure resident was adequately fed, it was alleged that R1 had a high sodium level which indicates a possibility that R1 was not being properly fed. LPA's record review on 08/18/23 at 1:30 PM and today at 10:00 AM revealed that R1 had no dietary restriction. LPA's interview with three (3) care staff on 08/18/23 between 10:15 AM to 1:30 PM, revealed that all three (3) staff interviewed stated that R1 was on tray service and always eat regularly with no dietary restriction. LPA's interview with R1's roommate today at 1:15 PM today confirmed that R1 eats regularly, and staff brought R1's food to R1 everyday every meal.

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: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

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