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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850126
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:14:01 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
10/03/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20221003140042
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:
10/25/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Tsisana “Ana” Mikia, caregiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff attempted to lift resident causing resident to fall.
Staff left multiple residents in soiled diapers for a period of time.
Staff did not provide residents meals in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Emily Peraldi and Martha Arroyo conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 10:35 a.m., the LPAs met with staff and explained the reason for the visit. At 2:31 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.

During the initial visit on 10/04/2022 between 11:08 a.m. and 11:30 a.m., LPAs Emily Peraldi and JoAnn Rosales toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Additionally, at 11:31 a.m., the LPAs reviewed resident records. During a subsequent visit conducted on 10/05/2022 at 9:58 a.m., LPA Peraldi conducted a physical plant tour. On 10/05/2022 at 11:17 a.m., LPA Peraldi conducted an interview with the Licensee. Additionally, on 10/05/2022 between 11:21 a.m. and 11:54 a.m., LPA Peraldi conducted interviews with four (4) out of six (6) residents. During today’s visit at 10:49 a.m., the LPAs conducted a physical plant tour and at 12:50 p.m., the LPAs conducted a file review. On 10/25/2022, LPA Peraldi also conducted an interview with staff at 10:51 a.m. Continued on LIC 9099-C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
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)
Page: 1 of 5
Control Number 29-AS-20221003140042
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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Regarding the allegation: Staff attempted to lift resident causing resident to fall.
It was alleged that Staff #1 (S1) attempted to lift Resident #1 (R1) and in the process R1 fell. On 10/05/2022, LPA Peraldi conducted an interview with the Licensee. The Licensee stated that the residents haven’t fallen as of recently. Interviews with residents revealed that there has not been falls recently. On 10/25/2022 at 10:55 a.m., LPA Peraldi interviewed S1. S1 stated that residents have not had falls in the month of October and that everyone has been good. 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.

Regarding the allegation: Staff left multiple residents in soiled diapers for a period of time.
It was alleged that multiple residents were left with soiled diapers for a long period of time. During the initial visit on 10/04/2022 at 11:08 a.m., LPA Peraldi and LPA Rosales observed resident room #1 having a strong smell of urine. However, interviews with residents conducted on 10/05/2022, revealed that the staff have been changing residents’ diaper. 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.

Regarding the allegation: Staff did not provide residents meals in a timely manner.
It was alleged that the staff was not providing meals to residents in a timely manner. During the subsequent visit on 10/05/2022, resident interviews revealed that residents did not have an issue with the time that meals were being delivered. No additional concerns or comments regarding meals were given during resident interviews. During the subsequent visit on 10/25/2022, the LPAs observed S1 serving lunch at 11:23 a.m. and preparing additional lunch at 1:20 p.m. The information obtained during the investigation did not include evidence sufficient 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
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)
Page: 2 of 5
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
10/03/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20221003140042

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:
10/25/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Tsisana “Ana” Mikia, caregiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff is insufficient in numbers to meet the residents needs.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Emily Peraldi and Martha Arroyo conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 10:35 a.m., the LPAs met with staff and explained the reason for the visit. At 2:31 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.
During the initial visit on 10/04/2022 between 11:08 a.m., and 11:30 a.m., LPAs Emily Peraldi and JoAnn Rosales toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Additionally, at 11:31 a.m., the LPAs reviewed resident records. During a subsequent visit conducted on 10/05/2022 at 9:58 a.m., LPA Peraldi conducted a physical plant tour. On 10/05/2022 at 11:17 a.m., LPA Peraldi conducted an interview with the Licensee. Additionally, on 10/05/2022 between 11:21 a.m. and 11:54 a.m., LPA Peraldi conducted interviews with four (4) out of six (6) residents. Case Management visits were also conducted on 10/04/2022, 10/14/2022, 10/15/2022 and 10/16/2022. During today’s visit at 10:49 a.m., the LPAs conducted a physical plant tour and at 12:50 p.m., the LPAs conducted a file review. On 10/25/2022, LPA Peraldi also conducted an interview with staff at 10:51 a.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
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)
Page: 3 of 5
Control Number 29-AS-20221003140042
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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Regarding the allegation: Staff is insufficient in numbers to meet the resident’s needs.
It was alleged that at the time the complaint was received, the facility had staffing shortage as the main staff, Staff #1 (S1) quit working at the facility on 10/03/2022. On 10/03/2022 at 3:21 p.m., the LPA spoke with the Licensee and the Licensee confirmed that S1 quit and the Licensee stated that they were currently at the facility. The Licensee confirmed that they will be working at the facility until the Licensee hires another caregiver. From 10/03/2022 until 10/16/2022, the Licensee was attempting to hire new caregivers. Interviews with residents during the Case Managements visits on 10/14/2022 and 10/15/2022, revealed that on 10/11/2022, 10/12/2022 and on 10/14/2022 staff did not assist the residents with the self-administration of medications. Additionally, on 10/25/2022 at 12:50 p.m., the LPAs conducted a file review and observed that Centrally Stored Medication Record and Medication Administration Record (MAR) has not been filled out since August 2022. Based on the information and documentation gathered throughout the investigation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report was issued and appeal rights was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
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)
Page: 4 of 5
Control Number 29-AS-20221003140042
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
87411(a)
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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Administrator agreed to submit an updated facility staff schedule and a Statement of Understanding, demonstrating how the facility will maintain adequate staffing to meet the needs of the residents. These documents must be submitted to Community Care Licensing by 10/26/22.
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Based on observations, interviews and record review, the Licensee did not comply with the section cited above as there was a staffing shortage which caused residents to not receive their medications on time which poses an immediate health, safety and personal rights risk to residents 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: 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)
Page: 5 of 5