195850126-11-8-2022-29-AS-DPEA-CMA2VZ-20221219164444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850126
Report Date: 11/08/2022
Date Signed: 11/08/2022 03:00:25 PM

Unsubstantiated

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
11/04/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20221104160218

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: 4	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Tsisana “Ana” Mikia, caregiver		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit at the facility today. At 12:45 p.m., the LPA met with staff and explained the reason for the visit. At 12:54 p.m., LPA Peraldi spoke with the Licensee. The Licensee was not available during today’s visit and authorized staff, Tsisana “Ana” Mikia to sign the report.

At 1:10 p.m., the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Between 1:12 p.m. and 2:20 p.m., the LPA interviewed four (4) out of four (4) residents. At 12:50 p.m., the LPA conducted an interview with Staff #1 (S1). At 12:54 p.m., the LPA conducted a telephonic interview with the Licensee. At 1:57 p.m., the LPA conducted a record review.

Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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-20221104160218

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: 11/08/2022

NARRATIVE

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Regarding the allegation: Unlawful Eviction.
It was alleged that Resident #1 (R1) was being forced to move out of the facility in order for a new resident to be moved in. During the initial visit, the LPA interviewed the Licensee. The Licensee stated that the placement agency that placed R1 at the facility called R1 and told R1 that R1 had to leave the facility. R1 refused and did not want to leave. The Licensee stated that they told R1, if R1 does not want to leave the facility R1 does not have to. The Licensee confirmed that R1 is staying at the facility and is not leaving. Interviews with staff revealed that the Licensee was not the one that wanted R1 to move out, but that the placement agency wanted R1 to move to another facility. During the record review, the LPA was not able to find the name of the placement agency. Facility staff and residents did not know the name of the placement agency or the name of the representative of the placement agency. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

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