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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850126
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:07:00 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
02/22/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230222095031
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: 0DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Arsen DavtyanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff did not ensure that facility front door was closed.
Facility staff was asleep while at work.
Facility staff did not ensure that residents' private information was inaccessible.
Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit at this location. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. The Licensee was not available during the time of the visit, and authorized staff, Arsen Davtyan to sign the report.

At 10:36 a.m., the LPA conducted a physical plant tour. At 10:40 a.m., the LPA conducted an interview with Staff #1 (S1). At 2:21 p.m. and 2:25 p.m., the LPA interviewed two (2) out of three (3) residents. At 2:36 p.m., the LPA conducted an interview with the Licensee.

Continued on LIC 9099-C.

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: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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-20230222095031
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: 03/01/2023
NARRATIVE
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Regarding the allegation: Facility staff did not ensure that facility front door was closed. The Department received a complaint 02/22/2023 alleging that the facility is not safe, healthful, and a comfortable environment due to staff leaving the front door wide open. A credible witness arrived at the facility on 02/16/2023 and upon arrival the front door was wide open. The credible witness walked in and was able to tour the facility and speak with residents without staff noticing. Furthermore, the credible witness provided evidence of the facility front door being wide open on 02/16/2023. Interview conducted on 03/01/2023 with S1 confirmed that the door was open when the credible witness was at the facility. Based on the information provided by a credible witness, and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Regarding the allegation: Facility staff was asleep while at work. The Department received a complaint 02/22/2023 alleging that the only staff at the facility was asleep while at work. On 02/16/2023, a credible witness arrived at the facility. The credible witness provided evidence that the facility front door was wide open, and the credible witness walked in and was able to tour the facility and speak with residents without staff noticing. The credible witness noted that S1 was asleep for proximately 45 minutes. Interview conducted on 03/01/2023 with S1 confirmed that S1 was asleep during work on 02/16/2023 while the credible witness was at the facility. S1 stated that “it won’t happen again.” Based on the information provided by a credible witness, and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Regarding the allegation: Facility staff did not ensure that residents' private information was inaccessible. The Department received a complaint 02/22/2023 alleging that the facility had resident’s medical information out in the common area. On 02/16/2023, a credible witness arrived at the facility and toured the facility. The credible witness observed resident’s medical information on top of a filing cabinet. Interview conducted on 03/01/2023 with S1 confirmed that there were residents’ folders accessible in the common area. S1 stated that the resident’s folders and other private information has since been made inaccessible. S1 stated that all resident information is locked inside a filling cabinet. Based on the information provided by a credible witness, and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230222095031
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: 03/01/2023
NARRATIVE
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Regarding the allegation: Facility has pests. The Department received a complaint 02/22/2023 alleging that the facility had dead cockroaches and a large spider in resident rooms and restrooms. On 02/16/2023, a credible witness arrived at the facility and toured the facility. While touring the facility the credible witness observed the following: A spider In Bedroom #1, and dead cockroaches in bedroom #2 and in the hallway bathroom. Furthermore, the credible witness provided evidence of the cockroaches and spider. Interview conducted on 03/01/2023 with S1 revealed that S1 cleans the facility on the daily and as needed. Based on the information provided by a credible witness, 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 and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230222095031
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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2023
Section Cited
CCR
87411(a)
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87411 (a) Personnel Requirements – General (a) 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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No POC can be provided as this facility closed on 2/21/2023.
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Based on observations from a credible witness and interviews, the licensee did not comply with the section cited above as S1 was asleep while at work which poses an immediate health and safety risk to residents in care.
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Type B
03/01/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 (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, furnishings and equipment. This requirement is not met as evidenced by:
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No POC can be provided as this facility closed on 2/21/2023.
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Based on observations from a credible witness and interviews, the licensee did not comply with the section cited above as the facility front door was wide open which poses a potential health and safety 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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230222095031
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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2023
Section Cited
CCR
87506(c)
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87506 (c ) Resident Records (c) All information and records obtained from or regarding residents shall be confidential. This requirement is not met as evidenced by:
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No POC can be provided as this facility closed on 2/21/2023.
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Based on observations from a credible witness and interviews, the licensee did not comply with the section cited above as there was resident’s private information accessible in the common area which poses a potential health and safety risk to residents in care.
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Type B
03/01/2023
Section Cited
CCR
87303(a)
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87303 (a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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No POC can be provided as this facility closed on 2/21/2023.
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Based on observations from a credible witness and interviews, the licensee did not comply with the section cited above as the facility had cockroaches and spiders in resident rooms and restroom which poses a potential health and safety 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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5