195850126-10-25-2022-29-AS-DPEA-CMCTNF-20221222135239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850126
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:13:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20221018140937

FACILITY NAME:	GOLDEN CENTURY ASSISTED LIVING INC		FACILITY NUMBER:	195850126
ADMINISTRATOR:	SANDY KHAMBEKYAN		FACILITY TYPE:	740
ADDRESS:	13303 REEDLEY STREET		TELEPHONE:	(747) 264-0032
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 5	DATE:	10/25/2022
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Oganes “John” Duymalyan		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff not wearing masks.

Chemicals are accessible to resident's in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's), Martha Arroyo and Emily Peraldi conducted an unannounced complaint investigation for the above allegations at 10:35am. Upon arrival, the LPA’s rang the doorbell, but there was no answer. The LPA’s turned the front doorknob, but it was locked. Shortly after, the LPA’s were greeted at the door by staff, Tsiana (Anna) Mikia and the reason for the visit was explained. Entrance interview.

During today's inspection, at 10:49am, the LPA’s toured the facility to ensure there are no health and safety concerns.

It was alleged that staff are not wearing masks. Information was received through a credible witness stating that while visiting the facility, they observed staff was not wearing a mask, nor did they put on a mask at any time during the visit. Upon arrival to the facility, the LPA’s observed one staff, Staff #1 (S1) wearing a mask, and one (1) visitor not wearing a mask. (...Report Continued on LIC 9099C...)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221018140937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/25/2022

NARRATIVE

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(...Report Continued from LIC 9099...)

However, while at the facility, the LPA’s observed S1 continuously placing their mask down to their chin. Based on LPA observation and the credible witness statement, the allegation of “staff are not wearing masks” is deemed Substantiated at this time.

It was also alleged that chemicals are accessible to resident’s in care. Additional information received by a credible witness reported that laundry detergents were observed to be in an unlocked cabinet above the laundry machines in the hallway. Furthermore, chemicals were also observed in another unlocked cabinet under the kitchen sink. During the plant tour, between 10:50am and 10:54am, the LPA’s observed over-the-counter medications which included a tube of Careall Vitamin A & D Ointment and a bottle of SAF-Clens Advanced Formula Dermal Wound Cleanser unlocked and accessible to residents in care. During the visit, staff immediately locked and secured the items making them inaccessible to residents in care. Based on LPA observation and evidence provided by a credible witness, the allegation of “chemicals are accessible to residents in care” is deemed Substantiated at this time.

Although both allegations were Substantiated. Chemicals accessible to residents in care were cited on an unrelated inspection on 7/20/2022 and 10/14/2022.

Exit interview conducted. Appeal Rights and report were reviewed with staff, and a copy will be provided to the Licensee via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221018140937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2022 Section Cited CCR 87469.1(a)(2)	1 2 3 4 5 6 7	87469.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee Representative has agreed to review PIN 21-38-ASC, and will conduct an in-house training on proper mask wearing and submit to CCL by 10/26/2022.
	8 9 10 11 12 13 14	Based on LPA observation, the licensee did not comply with the section cited above as S1 was not wearing a mask properly and a visitor was not wearing a mask while inside the facility, 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
	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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC9099 (FAS) - (06/04)

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