197609621-4-5-2024-31-AS-TAGD-DABSGQ-20241023135215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 04/05/2024
Date Signed: 04/05/2024 02:31:43 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
04/02/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240402133640

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:	DATE:	04/05/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Yesenia Acosta - Staff		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not maintain resident's records

Staff did not provide adequate transportation to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegations. LPA met with staff Yesenia Acosta who called the administrator and explained the reason for the visit. The administrator designated Ms. Acosta to sign the report.

LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents relevant to the investigation at 10:02 AM and interviewed staff and residents between 10:30 AM to 1:00 PM. Regarding the allegation that Staff did not maintain resident's record, it was alleged that staff misplaced Resident #1 (R1)'s medical records and were not able to provide copies to RP. LPA's record review today at 1:05 PM revealed that the facility has no hospital record on file, only from the doctor's office. LPA's interview with staff today at 11:49 AM revealed that whenever a resident was hospitalized at any hospital, the hospital provides the discharge paper to the resident, and it was up to the resident to give or provide a copy to the facility. The facility is not directly provided any hospitalization record by any hospital. (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: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

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-20240402133640

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: 04/05/2024

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff did not provide adequate transportation to resident in care, it was alleged that staff would transport R1 to doctor's appointments and drop R1 off at the entrance of the medical building and not go inside with R1. LPA's record review today at 1:05 PM revealed that the facility only provides arrangement of transportation to any resident if they need assistance. Further review also revealed that R1 was legally blind (one eye) and had the capacity for self-care and was ambulatory. LPA's interview with staff today between 10:30 AM to 1:00 PM revealed that when R1 was still living at this facility, R1 was independent and goes in and out of the facility to buy personal needs and meet with love partner at any time.
Based on the information gathered during this 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: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC9099 (FAS) - (06/04)

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