197609621-8-7-2021-31-AS-NMAN-C6UQ6S-20210914115400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 08/07/2021
Date Signed: 08/07/2021 03:35:34 PM

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
07/23/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200723141416

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: 107	DATE:	08/07/2021
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Marilyn Nguyen - Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff are not providing a comfortable environment
Lack of supervision resulting in residents engaging in a physical altercation
Lack of supervision resulting in residents engaging in verbal altercations
Facility staff did not prevent a resident from smoking in the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegations. LPA met with licensee Marilyn Nguyen and explained the reason for the visit.

LPA conducted physical plant tour at 9:00 AM. Requested copy of facility documents relevant to the investigation at 9:30 AM and conducted interviews with staff and residents between 10:00 AM to 1:30 PM.

Regarding the allegation that the facility are not providing a comfortable environment, It was alleged that Resident #1 (R1)'s neighbor, Resident #2 (R2), disturbed R1 by being loud and shouting in R2's room, in the balcony and hallway. LPA interview with six (6) residents between 10:00 AM to 1:30 PM, living near and beside the rooms of R1 and R2 revealed that no one witnessed or heard R2 shouting in R2's room or in the balcony or hallway. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2021

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-20200723141416

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: 08/07/2021

NARRATIVE

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(continued from LIC 9099)

LPA interview with Resident #3 (R3) who is R2's room mate for more than a year, confirmed that R3 did not witness R2 shout in their room, in their balcony or in the hallway. Moreover, LPA interview with the administrator on 07/27/2020 at 11:00 AM and two (2) staff at 1:05 PM today, also revealed that they did not receive any report nor there is any record of R2 misbehaving or shouting in the facility disturbing any resident.

Regarding the allegation that lack of supervision resulting in residents engaging in a physical altercation. It was alleged that R2 has beaten up a resident. LPA interview with six (6) residents living near and beside the rooms of R1 & R2, revealed that they did not witness R2 beating up anyone at the facility. In addition, LPA interview with R1 on 08/20/20 at 11:07 AM revealed that R1 was not able to identify the resident who was allegedly beaten up by R2. R2 denied the allegation during interview today at 10:55 AM. Further, interview with the administrator on 07/27/2020 at 11:00 AM and two (2) staff today at 1:05 PM, also revealed that they did not receive any report nor there is any record of R2 having a physical altercation nor assaulted anyone at the facility.

Regarding the allegation that lack of supervision resulting in residents engaging in verbal altercation. It was alleged that R2 was "going around threatening and physically assaulting people". LPA interview with six (6) residents living near and beside the rooms of R1 & R2, revealed that they did not witness R2 having a verbal altercation nor threaten anyone at the facility. In addition, LPA interview the administrator on 07/27/2020 at 11:00 AM and with two (2) staff today at 1:05 PM, also revealed that they did not receive any report nor there is any record of R2 having a verbal altercation nor threaten anyone at the facility.

Regarding the allegation that Facility staff did not prevent a resident from smoking in the facility, LPA interview with six (6) residents living near and beside the rooms of R1 & R2, revealed that they did not witness R2 smoking inside the facility. LPA interview with R3 who is R2's room mate for more than a year, revealed that R2 did not smoke in their bathroom. LPA interview with the administrator on 07/27/2020 at 11:00 AM and two (2) staff today at 1:05 PM, also revealed that they did not receive any report nor there is any record of R2 smoking inside the facility.

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2021

LIC9099 (FAS) - (06/04)

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