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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:41:24 PM


Document Has Been Signed on 12/13/2022 03:41 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:
12/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Arsen Davtyan, staffTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Emily Peraldi and Brian Balisi, arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. At 12:48 p.m., the LPAs were greeted by staff. At 12:58 p.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, Arsen Davtyan to sign the report.

At 12:55 p.m., the LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards. At 1:10 p.m., the LPAs reviewed records. Between 1:26 p.m. and 2:30 p.m., the LPAs interviewed two (2) residents and Staff #1 (S1) and Staff #2 (S2). Prior to visit, LPA Peraldi printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed S1 is newly hired. Per record review, conducted by LPAs on the Guardian website, S1 is in the process of getting fingerprint clearance. Interviews with the Licensee and staff revealed that S1 started working at this facility on 12/01/2022. Records reviewed include, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. No records were available for S1 and S2 at this time, including hours of training.

At 1:59 p.m., LPA Peraldi spoke with the Licensee regarding the recent staffing shortage. LPA reminded the Licensee that staff that are not fingerprinted or are not associated to the facility cannot be working at the facility. LPA Peraldi also requested the staff schedules. 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 $500. 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: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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 3


Document Has Been Signed on 12/13/2022 03:41 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: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
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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Licensee agreed to get S1 a criminal record clearance and ensure all staff are associated to the facility by 12/14/2022.

Civil Penalties assessed in the amount of $500.
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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 S1 which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
12/23/2022
Section Cited

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87412(a)Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
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The Licensee has agreed to the following:
1. Submit the completed personnel file via fax or email for S1 and S2 by POC due date.
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Based on record review and interview the licensee did not comply with the section cited above as S1 and S2 records were not maintained which poses a potential 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: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/13/2022 03:41 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: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited

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87411(c) Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
This requirement is not met as evidenced by:
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The Licensee has agreed to the following:
1. Submit proof of training for S1 and S2 via email or fax to LPA by POC due date.
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Based on record review and interview the licensee did not comply with the section cited above in S1 and S2 training hours were not available to review during the visit which poses a potential 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: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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