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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850126
Report Date: 10/25/2021
Date Signed: 10/25/2021 07:11:18 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210719103031
FACILITY NAME:GOLDEN CENTURY ASSISTED LIVING INCFACILITY NUMBER:
195850126
ADMINISTRATOR:HAYRAPETYAN, VIKTORYAFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(818) 416-0506
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 3DATE:
10/25/2021
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Anna Mikia, CaregiverTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Facility failed to address resident behaviors
Staff are not meeting residents' incontinence needs.
Staff are not meeting residents' showering needs.
Staff failed to treat resident with respect
Failure to provide adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) KaSandra Lopez and Teresa Camara conducted an unannounced, subsequent visit to deliver findings for the above allegations. LPAs met with caregiver Anna Mikia and informed her of the purpose of the visit. Administrator Akhtar “Ellie” Roshanaeian was unavailable to meet with LPAs.

Regarding the allegation: Facility failed to address resident behaviors:
On 07/19/2021, the Department received a complaint alleging that the facility failed to address resident behaviors. During a visit on 08/04/2021 at 2:09 p.m., LPAs Emily Peraldi and Ashley Smith observed Resident #1 (R1) wandering into the kitchen multiple times and attempting to open cabinets, including locked cabinets. R1 was also observed assisting Resident #2 (R2) to the restroom without staff noticing until LPAs alerted staff. Per record reviews, two (2) out of three (3) residents need special observations/night supervision due to

(Continued on 9099-C Page 2)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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 6
Control Number 29-AS-20210719103031
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
VISIT DATE: 10/25/2021
NARRATIVE
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confusion, forgetfulness and wandering. Interviews with Administrator Roshanaeian and Staff #1(S1) on 08/04/2021 beginning at 11:11 a.m., revealed there is only one (1) live-in staff working Monday through Friday. No other staff is scheduled during the week and the Administrator relieves S1 on Saturday and Sunday. Based on the information obtained and observations, there is sufficient evidence to support the claim that staff failed to address resident behaviors due to lack of staffing. This allegation is deemed Substantiated at this time.

Regarding the allegation: Staff are not meeting residents' incontinence needs:

It was alleged that staff are not meeting residents’ incontinence needs. During a visit on 08/04/2021 at 10:20 a.m., LPAs Peraldi and Smith observed R1 assisting R2 to the restroom. LPAs had to notify S1 of the situation. Per record review, R2 needs assistance with toileting needs. Staff interview conducted on 08/04/2021 at 11:11 a.m., indicated that R1 often urinates while walking towards the restroom and staff has to clean up after R1. Both R1 and R2 and are incontinent but tend to rip up their diaper briefs. Therefore, staff do not bother to put diapers on R1 and R2. Interview conducted on 08/04/2021 at 1:59 p.m. with the Administrator revealed that the Administrator is the only staff working on Saturdays and Sundays and does not change residents’ diapers while on duty. The Administrator relies on residents’ family members and hospice agencies to provide incontinence care for residents on the weekends. During today's visit at 12:29 p.m., LPAs observed R2 was left laying in soiled sheets until hospice staff arrived at the facility to clean R2. Based on the information obtained and observations, there is sufficient evidence to support the claim that staff are not meeting residents’ incontinence needs. This allegation is deemed Substantiated at this time.

Regarding the allegation: Staff are not meeting residents' showering needs:

It was also alleged that staff are not meeting residents’ showering needs. Staff interviews revealed some residents at the facility receive external care from hospice agencies for showering needs, but this does not preclude the licensee from assisting residents with bathing needs and other activities of daily living. Interviews with hospice revealed that they are unable to fully bathe/shower R3 due to difficulties of properly lifting R3 out of bed and onto the wheelchair. Interview with Administrator on 08/04/2021 at 1:59 p.m., revealed that some staff do not bathe residents, especially staff that work on the weekends. Based on the information obtained and observations, there is sufficient evidence to support the claim that staff are not meeting residents’ showering needs. This allegation is deemed Substantiated at this time.

(Continued on 9099-C page 3)

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210719103031
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
VISIT DATE: 10/25/2021
NARRATIVE
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Regarding the allegation: Failure to provide adequate food service:

It was alleged that the facility failed to provide adequate food service. During a visit on 08/04/2021, LPAs Peraldi and Smith observed staff cooking lunch for residents. Throughout the visit, LPA Peraldi observed S1 serve R2 snacks, including a plate of cookies and an ice cream bar. Upon resident record review on 08/05/2021, it is noted on R2’s physician’s report, dated 01/26/2021, that R2 is medically required to be on a pureed diet. An interview on 08/04/2021 at 11:11am, staff stated they cook whatever the residents request or enjoy eating. Based on LPA observation, S1 was unaware of R2’s modified diet requirement. During today's visit at 1:09 p.m., LPAs observed R2 eating lunch which consisted of ground beef, potatoes, vegetables and pizza; none of it was pureed. Based on the information obtained and observations, there is sufficient evidence to support the claim that the licensee fails to provide adequate food service. This allegation is deemed Substantiated at this time.

Regarding the allegation: Staff failed to treat resident with respect:

It was alleged that staff failed to treat resident with respect. Resident interviews on 08/04/2021 at 10:30 a.m., revealed that staff confront R3 because staff assumes that R3 lies to others about the facility. Interviews with staff on 08/04/2021 at 1:59 p.m., confirmed that staff confront R3 because staff believes R3 lies and talks badly about the staff behind their back. Based on the information obtained and observations, there is sufficient evidence to support the claim that staff failed to treat resident with respect. This allegation is deemed Substantiated at this time.

Pursuant to the California Code of Regulations, Title 22, the following deficiencies were issued during today’s visit. Exit interview conducted with Ms. Roshanaeian over the phone. Appeal rights issued and a copy of this report has been issued to the facility representative.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210719103031
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
Based on observations, R1 was assisting R2 to the restroom while S1 was busy. Two
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Administrator agreed to submit an updated facility staff schedule and a Statement of Understanding, demonstrating how the facility will maintain adequate staffing to meet the needs of the residents. These documents must be submitted to Community Care Licensing by 10/27/21.
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residents require close supervision. The facility only employs one staff during the week and the Administrator is the only staff on weekends, which poses an immediate health and safety risk to residents in care.

This is a repeat violation of this section. Civil penalty assessed. See LIC421FC.
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Type A
10/27/2021
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator agreed to submit a Statement of Understanding demonstrating how all facility staff, will provide incontinence care to all residents to meet their needs. This document must be submitted to Community Care Licensing by 10/27/21.
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This requirement is not met as evidenced by:
Based on interviews and observation, two incontinent residents are left without diapers, one left in soiled sheets and on the weekends the Administrator does not provide incontinence care or change diapers, which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210719103031
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2021
Section Cited
CCR
87464(f)(4)
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87464(f)(4) Basic Services. Basic services shall at a minimum include: (4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.
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Administrator agreed to submit a Statement of Understanding demonstrating how all facility staff, will bathe residents to meet their needs. This document must be submitted to Community Care Licensing by 10/27/21.
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This requirement is not met as evidenced by:
Based on interviews and observations, staff do not regularly bathe residents and rely on hospice staff to bathe residents, which poses an immediate health and safety risk to residents in care.
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Type A
10/27/2021
Section Cited
CCR
87555(b)(7)
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87555(b)(7) General Food Service Requirements. The following food service requirements shall apply: (7)Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
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Administrator agreed to follow food service requirements which includes R2's modified diet prescribed by R2's physician and will submit R2's modified diet menu to Community Care Licensing by 10/27/21.
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Based on observations and records, R2 is prescribed a pureed diet, however R2 was observed eating cookies and an ice cream bar, which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20210719103031
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
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Administrator agreed to submit a Statement of Understanding, demonstrating how the facility will ensure the personal rights of all residents. This document must be submitted to Community Care Licensing by 10/27/21.
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Based on observations and interviews, staff accuse resident of lying, which potenitally poses a health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6