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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 10/15/2022
Date Signed: 10/15/2022 09:58:12 AM


Document Has Been Signed on 10/15/2022 09:58 AM - 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: 4DATE:
10/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Oganes DuymalyanTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs), Martha Arroyo and Gary Tan conducted an unannounced Case Management-Other visit at this facility. Upon arrival, LPA's met with Licensee Oganes Duymalyan and was explained the reason for the visit. Entrance interview.

At 8:12 a.m., the LPA’s toured the facility with the licensee to ensure there are no health and safety concerns. Resident interviews were conducted between 9:13 a.m. and 9:35 a.m., a resident file review was conducted at 8:23 a.m., and copies of pertinent documents were obtained.

At 8:15 a.m., the LPA interviewed Staff #1 (S1) who stated they were hired on 10/14/2022 to spend the night at the facility to assist residents throughout the night. Interviews conducted revealed S1 is newly hired, and per Guardian Website, S1 does not have a criminal record clearance nor is associated to this 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 X 1 day. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. Appeal Rights and report were discussed with Licensee and a copy will be provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2022
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 10/15/2022 09:58 AM - 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: 10/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2022
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 interviews, the licensee did not comply with the section cited above as S1 does not have a criminal record clearance nor is associated to the facility, which poses an immediate health, safety and personal rights risk to persons in care.
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Civil Penalties assessed in the amount of $100.

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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2022
LIC809 (FAS) - (06/04)
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