197609621-12-11-2024-31-AS-TAGD-DFTSF9-20250417134955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:27:07 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
10/22/2024 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20241022101541

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:	12/11/2024
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Monique Lopez - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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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 at this facility to further investigate the above allegation. LPA met with Administrator Monique Lopez and explained the reason for the visit.

LPA conducted physical plant tour at 9:34 AM, requested copies of facility documents relevant to the investigation at 10:00 AM, reviewed records between 10:00 AM to 11:00 AM and interviewed resident and staff between 11:00 AM to 1:00 PM. It was alleged that Resident #1 (R1) had an infected abscess on the arm and was not sent to see medical attention. LPA's record review revealed that R1 did not have a skin condition upon admission on 08/13/24 and was ambulatory, able to bathe, care for own toileting needs, groom and dress and even manage own cash resources. R1 was not incontinent both bladder and bowel. LPA's interview with staff on 10/25/24 between 1:30 PM to 2:30 PM revealed that R1 was independent and able to go out alone to run own errand and/or meet with love partner outside of the facility. (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: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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-20241022101541

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: 12/11/2024

NARRATIVE

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(continued from LIC 9099)

LPA's interview with the same staff and the administrator today at 12:31 PM, revealed that when R1 showed the infected part of R1's body to them on 10/21/24, both the staff and the administrator told R1 to go to the hospital to have the skin condition be medically evaluated. R1 was sent to the hospital and was admitted on that same day. Further interview with the administrator today also revealed that R1 did not come back to the facility after that hospitalization but was officially discharged at the facility on 11/22/24.

Based on the information gathered during this and prior 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: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC9099 (FAS) - (06/04)

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