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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 08/08/2024
Date Signed: 08/08/2024 02:43:35 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
08/05/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240805162043
FACILITY NAME:GOLDEN ASSISTED LIVINGFACILITY NUMBER:
197609621
ADMINISTRATOR:LOPEZ, MONIQUEFACILITY TYPE:
740
ADDRESS:14060 ASTORIA STTELEPHONE:
(818) 367-1947
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:128CENSUS: 122DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Monique Lopez - AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with administrator Monique Lopez and explained the reason for the visit.

LPA conducted physical plant tour at 9:08 AM, requested copies of facility documents relevant to the investigation at 10:12 AM and interviewed staff between 10:30 AM to 12:30 PM. LPA also reviewed records between 12:30 PM to 1:30 PM. Regarding the allegation that Staff did not safeguard resident's personal belongings, it was alleged that Resident #1 (R1)'s belongings were thrown away by the while being away from the facility. LPA's record review today at 11:40 AM revealed that R1 was admitted at this facility on 04/20/2018 and was brought to the hospital on 11/20/23 due to R1's medical condition and has not been back at this facility since. Further review also revealed that R1 had a signed admission agreement and addendum specifically stating that if the resident leaves the facility for such reasons as hospital stay, skilled nursing care, or vacation. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20240805162043
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: 08/08/2024
NARRATIVE
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(continued from LIC 9099)

And if the resident is unable to or decided not to return to the facility, any belongings left behind at the facility will be held for 21 days and then be discarded. Since R1 left the facility and decided not to return to the facility since R1 left in 11/20/23, the allegation is deemed unsubstantiated at this time.

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: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2