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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609621
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:19:23 PM

Document Has Been Signed on 01/16/2025 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197609621
ADMINISTRATOR/
DIRECTOR:		LOPEZ, MONIQUEFACILITY TYPE:
740
ADDRESS:14060 ASTORIA STTELEPHONE:
(818) 367-1947
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 128TOTAL ENROLLED CHILDREN: 0CENSUS: 123DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Monique Lopez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Required One () year inspection to this facility. LPA initially met with Administrator Monique Lopez and explained the purpose of the visit.

At 10:25 AM, with the Administrator, LPA conducted a tour of the facility inside and out. The following were observed:

There is one main entrance being utilized at the facility. Screening area is located in the reception area. Sign in log book, hand sanitizer and masks are available. The facility had submitted and approved Mitigation Plan and Infection Control Plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signage were posted in the bathroom and all over the facility. The facility has a designated visitor's area in the front of the main building. The facility has sufficient stock of PPE in the storage room

The facility consists two (2) storey building and a basement. The facility is fire cleared for 128 ambulatory residents, sixty (60) of which maybe non-ambulatory. Hospice waiver for twenty five (25) residents. The basement has the Kitchen, Cafeteria, Activity room, Laundry Area, Staff break room and Storage rooms. There are sixty four (64) shared bedrooms with own bathroom and eight (8) public bathrooms. There were two (2) shaded smoking area in the surrounding backyard equipped with outdoor furniture. There is no body of water in the facility.

(continued to LIC 809-C)
Troy AgardTELEPHONE: (818) 596-4342
Jose Gary TanTELEPHONE: (323) 213-1149
DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/16/2025
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(continued from LIC 809)

Common Areas: The facility has two (2) elevators, both of which are working properly. The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on April 2024. The facility is equipped with sprinkler system which was last tested on 04/20/24 and valid until 04/30/26. Fire extinguishers are located all throughout the facility and were last serviced on 10/18/24. Fire Drill was last conducted on 01/03/25.

Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings, working signal system, grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 109.2°F to 114.4°F. There were enough clean linen available.



Basement: Kitchen and Cafeteria are located in the basement area the kitchen appeared clean, odorless and free from insects. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable foods. Frozen foods are wrapped and stored appropriately. Kitchen was observed to be inaccessible to residents. LPA observed however that the lunch being served is not the one on the menu for the day and there is no activity calendar posted anywhere in the facility. Laundry room is located in the basement and was observed to be locked during visit.

At 2:35 PM, LPA reviewed records of six (6) random residents and six (6) staff. Resident and staff records appeared to be complete and updated.

Medications were observed to be locked in the medication room and inaccessible to residents. There were two ( 2) complete first aid kits in the medication room.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Planned Activities
(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review there is no activity calendar posted in the premises so the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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The administrator agreed to create an Activity calendar upon consultation with residents and Activity assistant and submit a copy to CCL on or before the POC date.
Section Cited
Menus shall be written at least once a week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be available for review by the clients or their authorized representative and the licensing agency upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and recrod review, the menu is not being followed for every meal that being served in the faclility, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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The administrator will consult to the licensee and formulate a new menu for the facility and submit a statement that all the menu in the list will be prepared as listed on the menu and submit a copy to CCL on or before the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy AgardTELEPHONE: (818) 596-4342
Jose Gary TanTELEPHONE: (323) 213-1149

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025

LIC809 (FAS) - (06/04)
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