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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 10/04/2022
Date Signed: 10/04/2022 02:13:45 PM


Document Has Been Signed on 10/04/2022 02:13 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:SANDY KHAMBEKYANFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(747) 264-0032
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 6DATE:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH: Oganes Duymalyan, LicenseeTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Emily Peraldi and JoAnn Rosales arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. At 10:58 a.m., the LPAs were greeted by staff. At 11:00 a.m., the LPA spoke with the Licensee, Oganes Duymalyan and explained the reason for the visit.

Between 11:08 a.m. and 11:30 a.m., the LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards. At 11:31 a.m., the LPAs reviewed resident records.

Prior to visit, LPA Peraldi printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed that Staff #1 (S1) and Staff #2 (S2) are newly hired. Per record review, conducted by LPA Peraldi on the Guardian website, S1 does have a criminal record clearance but is not associated to this facility. S2 does not have their criminal record clearance. Interviews with the Licensee and staff revealed that S1 and S2 started working at this facility on 10/03/2022. Per record review, one (1) out of six (6) residents have dementia, (Resident #1).

At 11:09 a.m., the LPAs observed the hallway laundry doors broken making laundry detergent and cleaning supplies accessible to residents. At 11:10 a.m., the LPAs observed over the counter medications in room #1. At 11:13 a.m., the LPAs observed scissors in room #2. At 11:20 a.m., the LPAs observed eye drops in room #4. Upon observations, the Licensee removed and secured the items above, making them inaccessible to residents.

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: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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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Document Has Been Signed on 10/04/2022 02:13 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: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited

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87355(e)(1)Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... as required by the Department or
This requirement is not met as evidenced by:
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Based on record review and interview the licensee did not comply with the section cited by not getting a criminal record clearance for S2 which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
10/05/2022
Section Cited

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87355(e)(2)Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)...
This requirement is not met as evidenced by:
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Based on record review and interview the licensee did not comply with the section cited by not transferring the criminal record clearance for S1 to this facility prior to employment which poses an immediate health, safety and personal rights 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: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 10/04/2022 02:13 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: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
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 scissors were accessible (in room #2), which poses an immediate health and safety risk to persons in care.
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Type A
10/05/2022
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 eye drops were accessible (in room #1 and #4), 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: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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: 10/04/2022
NARRATIVE
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Additionally, on 10/04/2022 at 8:27 a.m., LPA Peraldi and Licensing Program Manager (LPM) Kristin Heffernan spoke with the Licensee regarding the recent staffing shortage. LPM reminded the Licensee that staff that are not fingerprinted or are not associated to the facility cannot be working at the facility. LPM and LPA Peraldi also requested the staff schedules. During todays visit, at 12:49 p.m., the LPAs had a conversation with the Licensee regarding staffing and emailed the Licensee Home Care Organization List. The Licensee stated that the facility will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $100, $100, $250, and $250. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, today's reports and appeal rights were provided via email Civil penalties issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4