197609621-3-28-2025-31-AS-TAGD-DFCQ9J-20250402115826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 10/31/2024
Date Signed: 03/28/2025 01:31:29 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
10/18/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20241018144046

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: 125	DATE:	10/31/2024
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff took away resident's television use
Staff took away resident's internet use
Staff did not provide adequate dining assistance to resident in care

INVESTIGATION FINDINGS:

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This report is being amended to rectify typographical and grammatical errors. No change in findings.
Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. 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 10:30 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 1:00 PM. Regarding the allegation that Staff took away resident's television use, it was alleged that the TV on Resident #1 (R1)'s room stopped working. LPA's observation during today's visit revealed that the TV set in R1's room had no antenna nor connected to a TV cable provider and only connected to the internet and has own internet service provider (ISP)'s modem and wi-fi router which belongs to R1’s roommate and R1 admitted that R1’s roommate was not paying the internet provider that is why there is no internet connection. (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: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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-20241018144046

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: 10/31/2024

NARRATIVE

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LPA's record review today between 10:30 AM to 11:30 AM revealed that nothing on R1's admission agreement states that the facility will provide a television or cable connection in R1's or any room at the facility. LPA's interview with the administrator on 10/25/24 at 11:30 AM confirmed that the facility only provides Cable TV services on the TV room and everyone is welcome to watch but not on individual rooms. Further interview also revealed that the facility staff would assist any resident who would like to get a cable/internet service on their room at their expense.

Regarding the allegation that Staff took away resident's internet use, it was alleged that the staff stopped R1’s internet connection. LPA's interview with the administrator at 12:00 PM, confirmed that the facility has internet connection and provide the password to the residents when they asked and denied stopping the connection of any resident at any time. LPA tested and connected to the facility's internet and observed to be working. LPA's interview with three (3) residents in the living area by the lobby revealed that they are connected to the facility's internet and the password were given by the administrator. LPA's observation during today's visit also revealed that the facility is expanding the internet coverage by adding wireless router on the far end area of the facility to enable any resident to connect to their internet connection.

Regarding the allegation that Staff did not provide adequate dining assistance to resident in care, it was alleged that staff are late on picking up R1 for lunch in the dining area. LPA's interview with the administrator on 10/25/24 at 11:30 AM and today at 12:17 PM, revealed that R1 is being served trays every day for breakfast and eat at the dining room for lunch and dinner. LPA's interview with R1 on 10/25/24 at 11:50 AM revealed that sometime the staff are late about ten (10) minutes but it is okay now and the staff now comes on time to pick up R1 for lunch. LPA's interview with two (2) staff today between 11:30 AM to 1:30 PM revealed that they usually pick up R1 ten (10) to twenty (20) minutes before lunch time but there are times that R1 was not ready so they had to go around and help other residents and come back which would cause their delay but they always try to come on time. Further interview also revealed that the only thing they do for R1 was to transfer R1 from bed to wheelchair which R1 could do alone at times.

Based on the information gathered during this and prior visit, these 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: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

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