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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:44:44 PM


Document Has Been Signed on 10/14/2022 03:44 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: 5DATE:
10/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Oganes DuymalyanTIME COMPLETED:
03:50 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) Kelly Dulek arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. At 10:38AM, the LPA was greeted by staff. At 10:58AM, the LPA spoke with the Licensee, Oganes Duymalyan. Licensee arrived at 11:52AM and LPA explained the reason for today's visit.

Beginning at 10:40AM and continuing throughout the visit., the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards. At 11:02AM, LPA reviewed records.

Prior to visit, LPA Dulek printed out the facility personnel report summary from the Guardian system. Upon arrival, it was revealed that Staff #1 (S1) is newly hired. Per record review, conducted by LPA on the Guardian website, S1 does not have a criminal record clearance. Interviews with the Licensee and staff revealed that S1 started working at this facility on 10/12/2022. Interview revealed that S1 has not been fingerprinted.

Upon arrival at 10:38AM, LPA observed a kitchen knife sitting out on the counter, accessible to residents. At 11:00AM, LPA observed medications in individual cups on the shelf, accessible to residents. 11:40AM, the LPA observed the file cabinet containing resident medications unlocked and accessible to residents. At 11:01AM, LPA observed a can of Clorox 4inOne Disinfecting Spray on the entry table, accessible to residents in care. At 12:25PM, LPA observed hallway laundry doors broken making laundry detergent accessible to residents. Per record review, one (1) out of (5) residents have dementia, (Resident #1). Upon Licensee's arrival and tour with LPA at 12:25PM, the Licensee removed and secured the items above, making them inaccessible to residents.

Previously, on 10/04/2022 at 8:27AM, LPA Emily Peraldi and Licensing Program Manager (LPM) Kristin Heffernan spoke with the Licensee regarding the recent staffing shortage. At that time, LPM reminded the

Report continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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 4


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: 10/14/2022
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
Licensee that staff that are not fingerprinted or are not associated to the facility cannot be working at the facility. Additionally during a visit on 10/04/2022 at 12:49PM, LPAs Emily Peraldi and JoAnn Rosales had a conversation with the Licensee regarding staffing and emailed the Licensee Home Care Organization List. At that time, 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. During today's visit, at 02:20PM, LPM Heffernan and Regional Manager Jill Nakata conducted a telephone call with the Licensee regarding the facility staffing plan.

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 $250, $250, and $300. 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) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/14/2022 03:44 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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited

1
2
3
4
5
6
7
87705 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 was not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the above section, as at 10:38AM a knife was observed out on the kitchen counter, the same knife was still on the counter accessible to residents when Licensee arrived, which poses an immediate safety risk to residents in care.
8
9
10
11
12
13
14
Type A
10/14/2022
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the above section, as Lysol spray and laundry detergent, medication was left unlocked and out on the shelf, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/14/2022 03:44 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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... as required by the Department
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4