195850126-12-17-2020-29-AS-EMIR-BWDV9L-20201217151431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 12/17/2020
Date Signed: 12/17/2020 03:17:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	GOLDEN CENTURY ASSISTED LIVING INC		FACILITY NUMBER:	195850126
ADMINISTRATOR:	LYSENKO, OLENA		FACILITY TYPE:	740
ADDRESS:	13303 REEDLEY STREET		TELEPHONE:	(818) 416-0506
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 6	DATE:	12/17/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Oganes Duymalyan		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Eva Miller conducted a Pre-Licensing Inspection with Applicant Representative Oganes Duymalyan and Administrator Olena Lysenko. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime". An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 4/30/20. A Fire Clearance was approved for a maximum capacity of six (6) residents, all of which may be non-ambulatory and 1 of which may be bedridden, on 09/03/20. The facility is currently operating as HERRIK HOME LLC - 197609108 and licensed to "Herrik Home LLC". The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Panorama City, CA. A tour of the physical plant was conducted and the following observed: KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient perishable food to accommodate a maximum capacity of six (6) residents for a minimum of two (2) days. There was sufficient nonperishable food to accommodate a maximum capacity of 6 residents for (seven) 7 days. Hot water delivered at 113F. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 Residents. There were no visible immediate hazards or discrepancies observed. BEDROOMS: There are four (4) Bedrooms, all of which are designated for Resident use. Bedrooms #2 and 4 are furnished for double occupancy. Bedrooms #1 and 3 are furnished for single occupancy. Bedroom #1 is designated as per the Fire Clearance for Bedridden use. There was appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC	FACILITY NUMBER: 195850126
	VISIT DATE: 12/17/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

BATHROOMS: There are two (2) full Bathrooms. The bathrooms are located inside Bedrooms #4 as well as between Bedrooms #2 & 3. The bathroom located between Bedrooms #2 & 3 is designated for both Resident and Staff use. The Bathroom located inside Bedroom #4 is designated for the use of the assigned occupants only. All Bathrooms were equipped with required grab bars and supplied with appropriate paper and hygiene products. There were no immediate visible hazards.

COMMON AREAS: These include the Living Room, Family Room and Dining Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. All required postings were located inside the main entrance. There was a hand sanitizing station inside the main entry. Required COVID-19 postings were located at the main entrance both interior and exterior and throughout the facility. Resident Medications and First Aid Kit are stored in a locked cabinet. There were no visible hazards or discrepancies.

GARAGE & LAUNDRY: Laundry applicances are located in a secured area in the hall outside of the bedrooms. The garage is used for storage only and is kept inaccessible to residents.

SURROUNDING GROUNDS: The Front Yard includes a driveway, paved walkways and landscaped areas. The backyard is fenced and includes paved walkways, landscaped areas, a patio, furniture appropriate for outdoor use and shade. There is an in-ground swimming pool that is fenced and gated and kept inaccessible to Residents. There were no visible immediate hazards or deficiencies.

COMPONENT III ORIENTATION; A Component III Orientation was conducted.

The following will be required before a license can be issued:

A revised Facility Sketch - Floor Plan (LIC 999) that documents all room dimensions.
A revised Facility Sketch - Yard (LIC 999) that documents walkways, driveways, fences, gates, overall yard size and a compass.

A copy of the Licensing Report was provided via email for signature and return.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2