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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 09/17/2021
Date Signed: 09/17/2021 04:25:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 INCFACILITY NUMBER:
195850126
ADMINISTRATOR:AKHTAR ROSHANAEIANFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(747) 264-0032
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 3DATE:
09/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Tsisana “Ana” Mikia TIME COMPLETED:
04:30 PM
NARRATIVE
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At 10:18 a.m. Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management-Deficiencies visit at the facility today due to deficiencies observed on 07/20/2021, 08/04/2021 and 09/17/2021 during the investigation of complaint control # 29-AS-20210719103031.

During today’s visit, LPA Peraldi was screened and greeted by staff Tsisana “Ana” Mikia and explained the reason for the visit. Administrator Akhtar “Ellie” Roshanaeian was not available during today’s visit and authorized Ana Mikia to sign the report.

At 10:30 a.m., LPA Peraldi interviewed staff #1 (S1). S1 stated that the census of the facility is three (3). LPA Peraldi asked about Resident #1 (R1), who was admitted to the facility on 09/02/2021. S1 explained that the R1 died shortly after being admitted but was unsure of the actual date. The licensee failed to report R1’s death to the Department. At 10:54 a.m., LPA Peraldi attempted to review R1’s records. However, the facility did not have any records for R1, besides R1’s admission agreement that was not signed. There was also no hospice care plan on file for R1 at the facility.

During a previous visit conducted on 07/20/2021, LPA Ashley Smith reviewed facility files and received copies of resident records. It was observed that two (2) out of three (3) residents did not have current appraisals.

During today’s visit at 10:54 a.m., LPA Peraldi reviewed resident records and again, two (2) out of three (3) residents did not have current appraisals. Resident record review also revealed one (1) out of two (2) residents, who have a diagnosis of Dementia, do not have a current physicians report on file. Two (2) out of three (3) residents’ admission agreements are not current, and are for previously licensed facility, Herrik Home LLC #197609108.

Continued on LIC 809-C.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2021
Section Cited

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87555 (b)(7) General Food Service Requirements: The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirement is not met as evidenced by:
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Based on observations, the licensee did not comply with the section cited above, as staff serves R2 cookies and other food that is not included in R2’s modified diet prescribed by R2’s physician, which poses an immediate health and safety risk to residents in care.
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Type A
09/17/2021
Section Cited

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87465(h)(6) Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
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Based on observation and record reviews, the Licensee did not comply with the section cited above as two (2) out of three (3) residents record of centrally stored prescription medications were missing which poses an immediate health and safety risk to residents in care.
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Administrator agreed to provide LPA with all residents centrally stored medication records by 09/18/2021.
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: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited

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87506(a)Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
This requirement is not met as evidenced by:
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Based on record reviews and observation, Licensee did not comply with the section cited above as the facility did not have any records for R1, besides R1’s admission agreement that was not signed which posed a potential health and safety risk to residents in care.
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Type B
09/20/2021
Section Cited

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87633(b) Hospice Care of Terminally Ill Residents: (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
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Based on record reviews and observation, Licensee did not comply with the section cited above as there was no hospice care plan on file for R1 at the facility which posed 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: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (A)Death of any resident from any cause regardless of where the death occurred...
This requirement is not met as evidenced by:
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Based on interview and record review, the licensee did not comply with the section cited above, as an incident report was not submitted for R1's death which poses a potential health and safety risk to residents in care.
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Type B
09/20/2021
Section Cited

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87463(c) Reappraisals
(c) The licensee shall arrange a meeting with the resident,...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first...
This requirement is not met as evidenced by:
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Based on record reviews, Licensee did not comply with the section cited above as two (2) out of three (3) residents do not have current appraisals 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: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited

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87705(c)(5) Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5)Each resident with dementia shall have an annual medical assessment...done at least annually...
This requirement is not met as evidenced by:
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Based on record reviews, Licensee did not comply with the section cited above as one (1) out of two (2) residents, who have a diagnosis of Dementia, do not have a current physicians report on file 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: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2021
NARRATIVE
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Continued from LIC 809.

During a subsequent visit conducted on 08/04/2021, LPA Peraldi observed Resident #2 (R2) eat a chocolate-covered ice cream bar and cookies. During today’s visit at 10:47 a.m., LPA observed staff give R2 cookies again. Per R2’s physician’s report, R2 is on a pureed diet. The facility is not providing a modified diet for R2 that is prescribed by R2’s physician.

At 1:09 p.m., LPA began a review of medications. Two (2) out of three (3) residents did not have centrally stored medication and destruction records. In addition, neither R1’s medication nor centrally stored medication and destruction record was observed.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6