195850126-2-24-2023-29-AS-DPEA-CPCSUL-20230224131119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850126
Report Date: 02/24/2023
Date Signed: 02/24/2023 11:38:45 AM

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
10/07/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20221007104718

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: 0	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Oganes Duymalyan, Licensee		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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**This report supersedes report issued on 01/30/2023. Report has been amended due to new information obtained***

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent telephonic complaint visit due to the facility been closed. At 10:49 a.m., the LPA contacted the Licensee to deliver complaint findings. LPA explained that the findings were amended

During the initial visit on 10/14/2022 between 10:40 a.m. and 1:12 p.m., LPA Kelly Dulek toured the facility and conducted with the Licensee and facility residents. At 11:02 a.m., LPA Dulek reviewed files. On 01/19/2023, LPA Peraldi conducted a telephonic interview with Resident #1 (R1). On 01/30/2023 at 12:49 p.m., LPA Peraldi conducted an interview with the Licensee. During today’s visit, LPA Peraldi conducted a physical plant tour at 1:10 p.m.

Substantiated

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: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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-20221007104718

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: 02/24/2023

NARRATIVE

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Regarding the allegation: Unlawful Eviction. It was alleged that Resident #1 (R1) was being evicted due to the Licensee stating that the facility was closing. During the telephonic interview conducted on 01/19/2023 by LPA Peraldi, R1 stated that the Licensee verbally notified R1 that the facility will be closing and that R1 needed to move out by the end of the week. According to the interview, R1 moved into the facility on 10/01/2022 and was told to move out of the facility by 10/07/2022. However, licensee never issued R1 with a proper written eviction notice. Additionally, interviews conducted with the Licensee revealed that he only informed R1 that the facility was closing. The licensee also admitted to not wanting to accept R1 back to the facility after the hospitalization due to R1 requiring additional care and supervision. Based on the information gathered during the course of the investigation, there is sufficient evidence to determine that the Licensee unlawfully evicted R1. Therefore, the above allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Appeal rights issued and a copy of this report has been issued to the Licensee via certified mail and email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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
10/07/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20221007104718

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:	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Oganes Duymalyan, Licensee		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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9

Fire Clearance- Licensee operating over capacity

INVESTIGATION FINDINGS:

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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: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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-20221007104718

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: 02/24/2023

NARRATIVE

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Regarding the allegation: Fire Clearance- Licensee operating over capacity. On 10/07/2022, the Department received a complaint alleging that the facility was operating over their capacity of six (6) residents. During the month of October, LPAs Peraldi, Rosales, Dulek, Arroyo, and Balisi conducted complaint and case management visits on 10/04/2022, 10/05/2022, 10/14/2022, 10/15/2022, 10/16/2022 and 10/25/2022 and the documented resident census ranged between four (4) and five (5). Additionally, on 01/19/2023, interview conducted with R1 stated that during R1’s stay at the facility there was never more than 6 residents. Interview with the Licensee conducted on 01/30/2022, the Licensee stated that the facility never operated over its capacity. 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 this report has been issued to the Licensee via certified mail and email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20221007104718

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: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/24/2023 Section Cited HSC 1569.682(a)(2)	1 2 3 4 5 6 7	1569.682(a)(2) Transfer of resident upon forfeiture of license or change in use of facility: Provide each resident’s responsible person with a written notice no later than 60 days before the intended eviction. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	No POC can be provided as this facility closed on 2/21/2023.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above, as there was no eviction notice issued R-1, which poses a potential personal rights risk to residents 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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5