197609621-9-11-2024-31-AS-NMAN-D9ASTM-20240920140946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:34:54 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
06/06/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240606130224

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:	09/11/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Monique Lopez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not prevent a resident from being hit while in care.

INVESTIGATION FINDINGS:

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

---Staff did not prevent a resident from being hit while in care.

It was alleged that Resident #2 (R2) hit Resident #1 (R1) on the face and R1 was unable to recall if it was left or right side of the face. R1 later referred to the alleged abuser as “visitor” and the reporting party reported no notable bruising or redness observed on R1's face. To investigate the allegation, on 06/11/2024, LPA conducted physical plant tour at around 2:00 PM, requested Staff Roster, Client Roster, Physician’s Report and Needs and Service Plan at 2:00 PM and interviewed the Administrator at 2:45 PM and six (06) residents between 2:45 PM to 03:30 PM.
(CONT. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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-20240606130224

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: 09/11/2024

NARRATIVE

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On 09/11/2024, LPA interviewed an additional three (03) staff from 12:00 PM – 1:00 PM. During the physical plant tour, LPA did not observe any signs of abuse and all residents were clean and well groomed. The department’s incident report files did not indicate any prior incidents involving the alleged abuser R2 and the alleged victim R1. During interviews with staff, all staff stated they are unaware of R2 hitting R1 or any other resident or visitor hitting R1. During interviews with residents, R1 stated they were not hit by R2 or any other resident or visitor. All other residents stated they have never hit a resident and do not know of any residents being hit by anyone, including visitors.

Based on observations, record reviews and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

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