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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 07/20/2022
Date Signed: 07/20/2022 04:47:01 PM


Document Has Been Signed on 07/20/2022 04:47 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: 3DATE:
07/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Tsisana “Ana” MikiaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. At 10:36 a.m., the LPA was greeted and screened by staff. At 11:52 a.m., the LPA spoke with the Licensee, Oganes Duymalyan and explained the reason for the visit. The Licensee was not available during today’s visit and authorized staff, Tsisana “Ana” Mikia to sign the report.

During a previous Collateral visit on, 07/14/2022 at 12:11 p.m., the LPA conducted a physical plant tour and reviewed records. At 12:13 p.m., the LPA observed Resident #1’s (R1’s) medications, over the counter medications and nutritional supplements in the living room area. The staff observed the items and secured the items making it inaccessible to residents during the visit. At 12:19 p.m., the LPA observed the hallway restroom, which has a missing toilet seat. At 12:48 p.m., the LPA observed the kitchen and the food supply. The facility did not have supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. At 1:15 p.m., the LPA reviewed resident files for, but not limited to: admissions agreements, medical assessment, updated appraisals, signed consent forms. The following was noted:
- No records or files for R1.
- No records or incomplete files for R2. Missing records include physicians report, and pre-placement appraisal. Incomplete files: Identification and Emergency Information, and admission agreement.

At 1:21 p.m., the LPA observed Resident #3 (R3) eating soup and a salad. Per R3’s physician’s report, R3 is on a pureed diet. The facility is not providing a modified diet for R3 that is prescribed by R3’s physician.

At 2:20 p.m., the LPA observed Resident #4 (R4) residing in room three (3), which is not the identified bedridden room. Per R4’s physician’s report, R4 is identified as bedridden. Per the fire clearance, a bedridden resident can only reside in Bedroom #1. At this time, R3, whom is ambulatory, is currently residing in Bedroom #1. An immediate civil penalty of $500 is assessed, due to a violation of the fire clearance.
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: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 07/20/2022
NARRATIVE
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During today’s visit, the LPA conducted a physical plant tour, reviewed records and interviewed staff between 10:38 a.m. and 12:46 p.m. At 11:46 a.m., the LPA interviewed Staff #1 (S1). S1 stated that R1 and Resident #5 (R5) recently passed away. S1 explained that R1 died on 07/17/2022 and that R5 died on 07/10/2022. However, S1 was unsure of the actual date of R5’s death. The Licensee failed to report R1’s and R5’s deaths to the Department. At 12:45 p.m., the LPA observed two (2) broken kitchen drawers, one (1) of which had knives making the knives accessible to residents. At 12:46 p.m., the staff observed the broken drawer, and relocated the knives to a secured locked drawer.

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. Civil Penalties assessed in the amount of $500, $250, $250, $250, $250, and $250. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report, civil penalties and appeal rights will be provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2022 04:47 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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited

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87465(h)(2)Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible...
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above as R1’s medications were not secured and were accessible to other residents which poses an immediate health and safety risk to persons in care.
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Type A
07/21/2022
Section Cited

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87705(f)(2)Care of Persons with Dementia
(f)...inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances... This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above as over the counter medications and nutritional supplements were accessible, which poses an immediate health and safety risk to persons 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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2022 04:47 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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited

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87202(a)(2) Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city... Prior to accepting or retaining any of the following types of persons... licensee shall notify the licensing agency...(2) Bedridden persons.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, R4 is bedridden and does not reside in the bedridden room, which poses an immediate health and safety risk to persons in care.
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This is a zero-tolerance violation, resulting in a civil penalty in the amount of $500. Print form LIC 421IM
Type A
07/21/2022
Section Cited

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87705(f)(1)Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above as knives were accessible, which poses an immediate health and safety risk to persons 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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2022 04:47 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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited

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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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Based on observations, the licensee did not comply with the section cited above, as staff serves R3 salad and other food that is not included in R3’s modified diet prescribed by R3’s physician, which poses an immediate health and safety risk to residents in care.
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Type A
07/21/2022
Section Cited

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87555(b)(26)General Food Service Requirements.(b)The following food service requirements shall apply:(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
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Based on observations, the licensee did not comply with the section cited above, as the facility did not have the required amount of nonperishable food and perishable foods 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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 07/20/2022 04:47 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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (A)Death of any resident from any cause regardless of where the death occurred...
This requirement is not met as evidenced by:
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Based on interview and record review, the licensee did not comply with the section cited above, as an incident report or death report was not submitted for R1's and R5’s death which poses a potential health and safety risk to residents in care.
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Type B
07/29/2022
Section Cited

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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:
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Based on record review, the licensee did not comply with the section cited above as there were no files or incomplete files present at the facility for R1 and R2 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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 07/20/2022 04:47 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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited

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87303 (a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Based on observations, the licensee did not comply with the section cited above, as the hallway restroom toilet has a missing seat, which poses an immediate health and safety risk to persons 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: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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