195850126-10-25-2021-29-AS-TCAA-C864ER-20211025190242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 10/25/2021
Date Signed: 10/25/2021 07:04:07 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 INC		FACILITY NUMBER:	195850126
ADMINISTRATOR:	AKHTAR ROSHANAEIAN		FACILITY TYPE:	740
ADDRESS:	13303 REEDLEY STREET		TELEPHONE:	(747) 264-0032
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 3	DATE:	10/25/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Anna Mikia, Caregiver		TIME COMPLETED:	05:25 PM

NARRATIVE

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Licensing Program Analysts (LPAs) KaSandra Lopez and Teresa Camara conducted an unannounced, Case Management-Other visit on 10/25/2021. LPAs met with caregiver Anna Mikia and informed her of the purpose of the visit. Administrator Akhtar “Ellie” Roshanaeian was unavailable to meet with LPAs.

On 10/22/2021, a telephonic conversation was held with facility representative Akhtar "Ellie" Roshanaeian and Community Care Licensing Division (CCLD) Regional Manager (RM) Jill Nakata, Licensing Program Manager (LPM) Kristin Heffernan and LPA Emily Peraldi. During the call, it was discussed that the facility license was previously issued to Golden Century Assisted Living, Inc. on 03/08/2021, despite Ms. Roshanaeian explaining that she bought the facility license from the previous licensee on 01/04/2021. However, as of 09/09/2021, the licensed corporation underwent a 100% change in ownership reflecting Ms. Roshanaeian as the only managing member, effectively replacing Oganes Duymalyan. RM Nakata reiterated to Ms. Roshanaeian that a CCLD facility license cannot be sold/purchased, and a new application would need to be submitted and approved in order to reflect her as the licensee. Ms. Roshanaeian stated she is debating on whether to file an application solely or as a partnership. Ms. Roshanaeian explained that she was considering partnering with another individual named Anna, but a last name was unknown. Ms. Roshanaeian also explained that she owns Comfortzone CAL, LLC. and would possibly submit an application under that limited liability corporation (LLC). LPM Heffernan explained that the LLC is not reflected on the California Secretary of State business website at this time.

A conversation was also held regarding staffing concerns. Ms. Roshanaeian explained the designated Administrator for the facility is Viktorya Hayrapetyan at this time. She stated she also has one caregiver who works Mondays-Saturdays. Ms. Roshanaeian stated she is at the facility on some days, nights and on the weekends to help. An updated staff schedule was requested to be submitted to the department.

(Continued on 809-C page 2)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: 10/25/2021

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After the call, the following information and resources were sent to Ms. Roshanaeian via email:

· Health & Safety Code 1568.061- regarding the forfeiture of license criteria.

· Health & Safety Code 1569.682/ Title 22 section 87224- regarding lawful eviction procedures.

· Link to CCLD’s Centralized Applications Bureau.

· Link to CCLD’s list of approved residential care facility for the elderly (RCFE) continuing education course vendors.

· Link to LIC 500 Personnel Report form.

· Link to LIC 9020A Register of Facility Residents for RCFEs.

It was also requested that Ms. Roshanaeian submit the following information to CCLD ASAP.

• Final decision of what Ms. Roshanaeian intends on doing with the facility.

• First and last name of potential business partner that she may be submitting an application with.
• Entity number for Comfortzone CAL, LLC. and proof of active state.
• Date of anticipated application submission with Community Care Licensing.
• Documents for Viktorya Hayrapetyan that designate her as the Administrator.
• LIC 500 – Personnel Report
• LIC 9020A – Resident roster for all THREE residents.
• All Plan of Correction documents that were requested via citations that were issued on 09/17/2021.

At this time, this property is considered unlicensed and a Notice of Operation in Violation of Law (NOVL) was issued to Ms. Roshanaeian. Exit interview conducted with Ms. Roshanaeian. A copy of report, citations and appeal rights issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 10/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2021 Section Cited	1 2 3 4 5 6 7	1569.10 RCFE; license or permit; necessity. No person, firm, partnership, association, or corporation within the state and no state or local public agency shall operate, establish, manage, conduct, or maintain a residential facility for the elderly in this state without a current valid license or current valid special permit therefor, as provided in this chapter.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on a telephone interview with the facility operator. The operator failed to comply with the section cited above as all three residents require care and supervision, which poses an immediate health and safety 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

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

LIC809 (FAS) - (06/04)

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