197609621-1-16-2025-31-AS-TAGD-DDRTBU-20250210133543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:52:19 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
05/15/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20240515161345

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: 123	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Resident developed a stage 4 pressure injury while in care

Resident sustained an unexplained fracture while in care

Staff did not seek medical attention to resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegations. LPA met with the Administrator Monique Lopez and explained the reason for today’s visit.

During the initial visit on 05/17/2024 at 12:16 PM, LPA obtained copies of the facility records, relevant to the investigation and interviewed the Administrator. This case was referred to and accepted by the Investigation Bureau (IB) and was assigned to IB Investigator Edward Hector, who conducted a separate investigation regarding the same allegations. During the course of the investigation, Investigator Hector interviewed a nurse from the Hospice services agency, facility staff, hospital staff, Resident #1 (R1) and R1’s family member and obtained medical records from the hospital and skilled nursing facility where R1 was discharged after hospitalization.

(continued to 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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240515161345

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: 01/16/2025

NARRATIVE

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(continued from LIC 9099-C)

Regarding the allegation that a resident developed a Stage 4 pressure injury while in care, it was alleged that Resident #1 (R1) had multiple pressure wounds including a stage 4 pressure wound when admitted to the hospital on 05/12/24. IB Investigator, Hector’s record review on 06/23/24 revealed that R1 was admitted to hospice on 11/30/22 and had been treating R1’s wound since then and the last visit for wound care was on 05/10/24. Investigator Hector’s interview with the hospice nurse on 07/23/24 at 4:32 PM, revealed that the nurse had been treating R1 since November 2022. When R1 presented with wounds, more frequent visits were implemented to care for R1’s wounds and an additional visit from Omni Wounds doctor was implemented to care for R1’s wounds. Further interview with the nurse also revealed that the facility communicated with the hospice agency regarding R1’s wound progress and overall health condition and kept R1 “dry” at all times. Additionally, the nurse and IB Investigator’s interview with the facility Administrator on 07/23/24 at 2:30 PM, R1 on 07/31/24 at 11:46 AM confirmed that R1, though wheelchair bound, was able to ambulate on R1’s own.

Regarding the allegation that Resident sustained an unexplained fracture while in care, it was alleged that R1 had a rib fracture when admitted to the hospital on 05/12/24. IB investigator Hector’s interview with hospital staff on 07/30/24 at 9:10 AM, revealed that the doctor who initially saw R1 did not report of chest/rib pain. Investigator Hector’s interview with the hospice nurse on 07/23/24 at 4:32 PM revealed that R1 never complained of any chest/rib pain while treating R1 therefore the hospice agency was not aware of R1’s rib fracture. Investigator Hector’s interview with the facility Administrator on 07/23/24 at 2:30 PM also revealed that they were not aware of R1’s rib fracture as R1 never complained of pain on the rib/chest area. Investigator Hector’s interview with R1 on 07/31/24 at 11:46 AM confirmed that even R1 was not aware of any rib fracture as R1 “didn’t feel it”.

Regarding the allegation that Staff did not seek medical attention to resident in a timely manner, it was alleged that R1 was admitted to the hospital for failure to thrive, declining mental and physical status. LPA’s record review on 05/17/24 revealed that R1 was admitted at the facility on 10/05/22 and was admitted to hospice care on 11/30/22 and was able to communicate their needs to the facility. Investigator Hector’s interview with the facility Administrator on 07/23/24 at 2:30 PM, revealed that R1 was declining since February 2024 but was still alert, oriented and still went outside the facility to smoke. (continued to LIC 9099-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240515161345

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: 01/16/2025

NARRATIVE

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(continued from LIC 9099-C)

LPA’s interview with the administrator on 05/17/24 at around 1:30 PM revealed that on 05/10/24, R1 complained of not being well but refused to go to the hospital and instead requested a family visit. Family members who regularly visit R1 came on 05/11/24 but another family member, a first-time visitor, came on 05/12/24 and called 911 for R1. R1 initially refused to go to the hospital but eventually agreed. Investigator Hector’s interview with R1 on 07/31/24 at 11:46 AM revealed that the facility provided assistance when R1 needed it and whenever R1 asked for it.

Based on the information gathered during the course of the investigation, including interviews, and record reviews, these allegations are deemed unsubstantiated at this time

Exit interview conducted and 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: 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

LIC9099 (FAS) - (06/04)

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