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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610357
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:06:22 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.RO, 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
04/30/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240430082015
FACILITY NAME:RM GOLDEN CAREFACILITY NUMBER:
197610357
ADMINISTRATOR:SARGSYAN, MAYAFACILITY TYPE:
740
ADDRESS:9030 WHITAKER AVENUETELEPHONE:
(747) 308-1111
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maya Sargsyan- AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff prevented resident from leaving the facility.
Staff did not seek medical care for resident in a timely manner.
INVESTIGATION FINDINGS:
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On 6.10.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations.

LPA was greeted by Maya Sargsyan who is the administrator of the facility.

An entrance interview was conducted.

At 1:33PM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation: Staff prevented resident from leaving the facility

Continue LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
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-20240430082015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RM GOLDEN CARE
FACILITY NUMBER: 197610357
VISIT DATE: 06/10/2024
NARRATIVE
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It was alleged that facility staff prevented resident #1 (R1) from leaving the facility. To investigate the allegations above, LPA conducted an initial visit on 5.06.2024. LPA toured the home and requested and reviewed the staff roster, resident roster, admissions agreement, appraisals, and incident reports. LPA interviewed staff and residents. LPA reviewed medical records on 5.10.2024. Interviews with two (2) staff and two (2) out of (4) residents that the above statement is untrue, and all residents expressed no concern regarding this allegation.

The investigation revealed that on 4.27.2024 R1 wanted to go to the library and see family who live in Orange County. R1 proceeded to exit the emergency door to leave the facility. Staff followed the resident and redirected the resident back to the home. R1 was hesitant in returning and decided to sit on the sidewalk and requested that 911 be called for the ambulance to take them to the library and Orange County. S2 was present and advised R1 that an ambulance is only for emergencies. R1 then stated that they were in pain, 911 was called and the resident taken to the hospital. Staff at no time prevented the resident from leaving the facility.

Based on the information received this allegation is Unsubstantiated at this time.

Allegation: Staff did not seek medical care for resident in a timely manner

It was alleged that staff did not seek medical care for R1 in a timely manner. To investigate this allegation, LPA conducted an interview with the staff and residents within the facility and was informed that due to R1 who frequently tries to leave the facility. Staff always re-directed R1 back to the facility, R1 advised staff that they wanted to go to the library or Orange County to visit their family. Interview with two (2) staff and two (2) out of (4) residents that the above statement is untrue, and all residents expressed no concern regarding this allegation. The interview also confirmed that there was no immediate health and safety risk to the resident, therefore 9-1-1 was not called until R1 stated they had hip pain. Ambulance took R1 to Southern California Hospital in Hollywood. From April 27, 2024, R1 was an inpatient, medical records show that R1 was given a series of radiology exams to evaluate the hip for any fracture and the results showed that the injury was old and healed. Based on interviews and record reviews this allegation is deemed unsubstantiated this time. Staff notified emergency services immediately when R1 stated they were in pain.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2