197609621-7-18-2024-31-AS-TAGD-DBSMFN-20241209083436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 07/18/2024
Date Signed: 07/18/2024 02:25:53 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
07/15/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240715090557

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:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff left resident on the floor for an extended period of time

INVESTIGATION FINDINGS:

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

LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents relevant to the investigation at 10:03 AM, reviewed records between 10:43 AM to 12:00 PM and interviewed residents and staff between 12:00 PM to 1:30 PM. It was alleged that Resident #1 (R1) fell on the floor for four (4) hours, and no one checked on R1. LPA interview with R1 today revealed that the incident happened on 06/16/24 but claimed that it happened at the facility and that two (2) female staff went by to R1's room at around 5:00 PM to deliver dinner and clean R1's bathroom but ignored R1 while lying on the floor. Reporting party (RP) who interviewed R1 reported that R1 fell two (2) days ago (07/16/24). LPA's record review today revealed that R1 was admitted only on 06/25/24. (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: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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-20240715090557

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: 07/18/2024

NARRATIVE

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(continued from LIC 9099)

LPA's review of the Closed-Circuit Television (CCTV) footage from 07/12/24 to 07/17/24 review today between 10:43 AM to 12:00 PM revealed that there is only one (1) female staff that may have delivered dinner to R1 during the period the RP reported. Staff #1 (S1) denied seeing R1 on the floor since R1's admission during interview. LPA's interview with the administrator also revealed that there is housekeeper scheduled to clean the bathroom of any resident in the afternoon unless a resident reported an "accident".

Based on the information gathered during this visit, the allegation is 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: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

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