<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 03/22/2022
Date Signed: 03/22/2022 07:07:12 PM


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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 INCFACILITY NUMBER:
195850126
ADMINISTRATOR:KATHLEEN LEITERMANFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(747) 264-0032
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 5DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kathleen Leiterman, AdministratorTIME COMPLETED:
07:15 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
At 10:00 a.m., Licensing Program Analysts (LPA) Emily Peraldi and Ashley Smith arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff and explained the reason for the visit. At 11:13 a.m., the Licensee Oganes Duymalyan arrived at the facility. At 1:10 p.m. Administrator Kathleen Leiterman arrived at the facility. This annual had a specific emphasis on infection control practices and procedures.

At 10:23 a.m., LPA Peraldi toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. At 10:20 a.m., LPA Smith conducted a file review for three (3) staff and five (5) residents.

COMMON AREAS: At 10:27 a.m., the LPA observed common area to be clean and properly furnished. LPA observed two fire extinguishers that were fully charged, but there was no indication as to whether they were serviced within the past twelve (12) months. However, the licensee purchased two new fire extinguishers during today’s visit. No deficiency cited. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. The facility smoke alarm system is hard wired. At 11:04 a.m., the smoke/carbon monoxide detectors were tested and functioned properly. LPA observed cameras installed in the hallways and common areas. However, the licensee removed the cameras. At 10:12 a.m. and at 10:50 a.m., LPA observed accessible cleaning solutions, and disinfectants throughout the common areas and hallways. Items were secured during today’s visit. The laundry units are located in the hallway. At 10:50 a.m., the LPA observed the broken laundry doors, making cleaning solutions accessible to residents. Upon observation, the staff secured and locked away the cleaning solutions and disinfectants. At 4:26 p.m., the LPA observed that the laundry door was fixed and can properly lock.

Continued on LIC 809-C.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the water registered above 120 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
During today's visit, the licensee adjusted the water temperature.
Once the water registers within regulation, submit a five day temperature log no later than 3/28/2022.
This is a repeat violation; civil penalty assessed in the amount of $250
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on obseevation, the licensee did not comply with the section cited above, as the exterior exit was blocked, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/22/2022
Plan of Correction
1
2
3
4
The exit was cleared during today's visit. Plan of Correction met.

This is a repeat violation; civil penalty assessed in the amount of $250

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 12 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as two out of five residents are bedridden and do not reside in the bedridden room, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/22/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Within 24 hours, the licensee will relocate the two residents to the room identified for bedridden residents only. Proof to be submitted to CCL by 3/23/2022 - end of day. CCL and Licensee will further discuss completing a new STD850 for the fire department to complete a new assessment. This is a zero tolerance violation, resulting in a civil penalty in the amount of $500
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as disinfectants and gardening supplies were accessible, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/22/2022
Plan of Correction
1
2
3
4
Items were secured during today's visit. Plan of Correction met.

This is a repeat violation; civil penalty assessed in the amount of $250

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 11 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three staff files (S3), which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Complete the health screening for S3; submit proof of completion by POC date.

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 5 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three staff (S3) which poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
1
2
3
4
The Administrator has agreed to the following:
1. Submit a written memo of understanding to how new staff will be trained per regulations by the POC date.
2. Submit completed 40 hours for S3 within the next four weeks.

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 14 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three staff (S2) which poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
1
2
3
4
The Administrator has agreed to the following:
1. Submit a written memo of understanding to how staff will complete the 20 hours annual training per regulations by the POC date.
2. Submit completed 20 hours for S2 within the next four weeks.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three staff (S3) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
1
2
3
4
The Administrator has agreed to the following:
1. Submit the completed first aid certification for S3 by POC due date.

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in one out of three staff (S3) which poses a potential health and safety risk to residents in care.
POC Due Date: 04/11/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Complete the 10 initial hours of medications training for S3. Submit proof by POC due date.
This is a repeat violation; civil penalties assessed in the amount of $250
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in one out of three staff (S2) which poses a potential health and safety risk to residents in care.
POC Due Date: 04/11/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Complete the 8 hours of annual medications training for S2. Submit proof by POC due date.

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 16 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in one out of five resident records (R1)which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Submit the signed copy of the Personal Rights form to CCL by POC due date.
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of five resident medication records (R3, R5) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Obtain the physician's orders for the PRN medications for R3 and R6. Submit proof to CCL by POC due date.

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 18 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of five resident files (R5) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Obtain the order for the bed-rail and submit proof to CCL. As R5 is not on hospice, R5 can only have a half bed rail.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of five resident files (R4) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Obtain the order for the full bed-rail and submit proof to CCL

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 15 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)
87632(a) Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above, as the facility only has a hospice waiver for two residents, yet there are four residents on hospice, which poses a potential personal rights risk to residents in care.
POC Due Date: 03/28/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Submit a Hospice Care Plan Waiver to the Department no later than POC due date.
Type B
Section Cited
CCR
87307(a)(2)(C)
87307(a)(2)(C) Personal Accommodations and Services (a) The following provisions shall apply: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above, as staff are going into a resident’s bedroom to use the master bathroom for personal use, which poses a potential personal rights risk to residents in care.
POC Due Date: 03/28/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Review regulation 87307. Submit a statement of understanding, noting how the staff will comply with regulation. Submit statement no later than POC date.
This is a repeat violation; civil penalties assessed in the amount of $250

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 18


Document Has Been Signed on 03/22/2022 07:07 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above for all resident files, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Audit the resident files. Compare the missing items to the LIC809 report. Submit completed/signed documents to CCL by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 13 of 18


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: 03/22/2022
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
KITCHEN: At 10:24 a.m., LPA observed the kitchen/dining area. Knives are stored in a locked kitchen cabinet inaccessible to residents. Kitchen appliances are in operable condition. The facility does not have sufficient supply of perishable and non-perishable food at the time of the visit. However, the facility obtained additional food during today’s visit. No deficiency cited. At 4:36 p.m., hot water measured at 126 degrees Fahrenheit. During today's visit, the licensee adjusted the water temperature.

BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms were clean and sanitary and in operating condition with grab bars. One (1) out of two (2) restrooms had non-skid mats present. Between 4:33 p.m. – 4:34 p.m., the hot water was measured in both the common hallway bathroom and the restroom in the master bedroom. Water temperature ranged between 127.8 – 128.5 degrees Fahrenheit. Staff interviews revealed that the staff use the master bathroom for personal use, yet the master bedroom is occupied by a resident. LPA observed that the facility had a common hallway bathroom and it appeared to be functional at the time of the visit.

OUTDOOR SPACE: LPA observed the backyard, which has a covered outdoor area for resident use. At 10:40 a.m., the LPA observed a fenced swimming pool with a self-latching gate with a lock. At the time of the visit, passageways and the emergency exit were not free and clear from obstruction. At 4:27 p.m., the LPA observed that the licensee removed the items blocking the emergency exit. Plan of Correction met.

RECORDS: Resident records were reviewed at 10:20 a.m. The LPA reviewed five files for, but not limited to: admissions agreements, medical assessment, updated appraisals, signed consent forms. Out of the five files review, the following was noted:

· Two out of five residents (Resident #1, Resident #4) need a signed admissions agreement


· Three out of five residents (Resident #1, Resident #2, Resident #4) need signatures for consent forms
· One out of five residents (Resident #3) needs a physician’s report with tuberculosis results,
· One out of five residents (Resident #1) needs a signed personal rights form
· Two out of five residents (Resident #4, Resident #5) were observed with full bedrails without an order
· One out of five residents (Resident #5) is not on hospice but has a full-bed rail on file.
· One out of five residents (Resident #1) needs a signed reappraisal
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 17 of 18
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: 03/22/2022
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
In addition, the facility has a Hospice Waiver on file for two residents, yet the facility currently has four residents on hospice.

At the time of the visit, two out of five residents (Resident #2, Resident #4) were identified as bedridden per their medical assessment. However, R2 and R4 are not in the identified bedridden room. Per the fire clearance, a bedridden resident can only resident in Bedroom #1. At this time, Resident #3, whom is non-ambulatory, is currently residing in Bedroom #1. An immediate civil penalty of $500 is assessed, due to a violation of the fire clearance.

Personnel records were reviewed at 10:51 a.m. The LPA reviewed records, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. The Administrator’s Certificate expires 04/16/2023. Out of the three files reviewed, one out of three staff (Staff #3) require first aid certification, and a medical assessment with tuberculosis screening results. In addition, the LPA was unable to identify the completed twenty (20) hours of annual training for Staff #2 (S2) nor could the LPA identify the initial forty (40) hours of training needed for S3. Lastly, the LPA could not identify the eight (8) hours of annual medications training for S2, or the ten (10) hours of initial medications training for S3.

MEDICATIONS: Medications are located in locked file cabinets. At 11:32 a.m., the LPAs conducted a medication audit for two (2) out of five (5) residents. The medication audit revealed that two (2) out of two (2) residents (Resident #3, Resident #5) required a prescription order for over the counter medications.

INFECTION CONTROL: LPA spoke with the Administrator and the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA discussed the protocol regarding visitation and the mandate regarding staff vaccinations.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Civil penalties assessed during today’s visit, see LIC 809-D. Exit interview was conducted and a copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 6 of 18