197609621-7-25-2021-31-AS-NMAN-C6VU2Q-20210915151219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609621
Report Date: 05/15/2021
Date Signed: 07/25/2021 05:16:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/15/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20201215102218

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: 110	DATE:	05/15/2021
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Marilyn Nguyen - Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not keep the facility free from bed bugs
Staff did not properly maintain the facility
Staff is withholding food from residents
Staff is withholding residents medications
Illegal eviction

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with licensee Marilyn Nguyen and explained the reason for the visit.

On 12/18/2020 LPA conducted virtual visit at the facility. LPA conducted virtual physical plant tour, obtained relevant facility records and interviewed administrator. During this visit, LPA conducted physical plant tour at around 9:45 AM and interviewed residents and staff of the facility at 10:45 AM. Regarding the allegation that the facility keep the facility free from bed bugs, LPA observation on Resident #1 (R1)'s room revealed that there was no bed bugs on R1's bed. LPA record review also revealed that the facility has contracted a pest control to visit monthly to prevent any infestation. Further, pest control invoices showed all common areas and fifteen (15) rooms are being treated monthly. LPA interview with administrator also revealed that if they received a report from resident about any infestation, the pest control gives priority to the reported room and/or area. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2021

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-20201215102218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN ASSISTED LIVING	FACILITY NUMBER: 197609621
	VISIT DATE: 05/15/2021

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that the staff did not properly maintain the facility, LPA interview with twelve (12) residents revealed that eleven (11) out of twelve (12) residents stated that their room is being cleaned everyday and LPA observation on multiple visit, virtual and physical, observed that the common areas are generally clean and organized.

Regarding the allegation that staff withheld food with resident, LPA interview with R1 revealed that by R1's own admission, that R1 did not eat at the facility and bought own food. LPA interview with staff confirmed that R1 does not eat at the dining area but was never refused any food if and when R1 asked for it. R1 also confirmed that although R1 does not receive food from the facility, when R1 is hungry, food will be provided to R1.

Regarding the allegation that Staff withheld medication, LPA interview with R1 revealed that R1 kept most of own medication except for PRN. LPA record review revealed that R1 is able to administer own and PRN medication. Further, medication log review also revealed that R1 refused to take own medication.

Regarding the allegation of Illegal eviction, LPA record review revealed that R1 was given an eviction notice due to non-payment, but was never evicted and still living at this facility to date.

Based on the information gathered during this visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted, copy of this report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2021

LIC9099 (FAS) - (06/04)

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