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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 10/25/2021
Date Signed: 10/25/2021 04:55:34 PM

COMPREHENSIVE INSPECTION
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:
10/25/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Tsisana “Ana” Mikia TIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) KaSandra Lopez and Teresa Camera conducted an unannounced Annual/Random inspection at the facility today. The LPAs met with staff Tsisana “Ana” Mikia at 10:14 AM and explained the reason for the visit. Administrator Akhtar “Ellie” Roshanaeian was contacted during the inspection and also advised for the reason of the visit. Ms. Roshanaein said she had medical appointment today and was not sure if she would be able to make it to the facility.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:27 AM, cheese and hot dogs in the refrigerator were opened and not stored properly. Chicken was also observed in the freezer in an open package and not stored properly.

BEDROOMS: The LPA observed two bedrooms for resident use. Bedrooms furnished appropriately and sufficient lighting. Prescription eye drops and a loose pill was observed on the tray in Resident #1 (R1) bedroom at 10:41 AM. Record review revealed R1 is not able to store their own medication. At 10:49 AM full bed rails were observed on the beds of Resident #2 (R2) and Resident #3 (R3). Record review revealed no record of R2 and R3 having an order from hospice for the bed rails.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed that the bathrooms was stocked with paper towels. At 10:47 AM the hot water temperature in the common hallway bathroom was observed to be 129.2 degrees F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
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)
Page: 1 of 7
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
NARRATIVE
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The smoke alarms and carbon monoxide detector were tested at 10:51 AM and were operational. The backyard has a covered outdoor area equipped with furniture for resident use. There is a fenced swimming pool with a self-latching gate which had a lock and was secured.

MEDICATIONS: At 10:55 AM medications were observed in a locked cabinet. The facility did not have current and complete centrally stored medication records for all three residents. All three residents were missing medications on their centrally stored medication records. During medication review, LPA Lopez observed medications not administered as prescribed. R2's medication Olanzapine 5 MG 30 QTY, one tablet a day at bed time was prescribed on 08/04/2021 and facility records indicate the medication was started on 08/04/2021, but the bottle still had medication left in it. R3's medication Mirtazapine 15 mg, 30 QTY one tablet at bedtime was prescribed on 09/29/2021 and was observed to have one pill and a half pill in the bottle.



FACILITY RECORDS: LPA Lopez began facility record review at 12:55 PM. The LPA reviewed the three resident files. One resident, (R2) out of one resident, has a diagnosis of dementia and has a medical assessment older than one year (signed by the physician 5/19/2020.) One resident, ( R1), out of three residents has an appraisal older than one year (dated 9/21/2020). Staff files were reviewed Staff #1 (S1) and Administrator Akhtar “Ellie” Roshanaeian. S1 did not have proof of receiving the 10 hour of initial medication training. LPA Lopez observed the first aid kit to be complete.

During the inspection, R2 was observed to have bruise below their eye and a cut above their eye. Staff said R2 fell at night about a week ago. CCL has no record of receiving an incident report for this incident.

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 and report reviewed with Administrator Akhtar “Ellie” Roshanaeian over the telephone at approximately 4:45 PM. Staff Tsisana “Ana” Mikia signed the report. Today's reports and appeal rights will be emailed to Ms. Roshaneaeian.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
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 7
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
11/05/2021
Section Cited

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87465(h)(2) Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Based on observation, the licensee failed to comply with the section cited above as R1 had a lose pill on their tray and prescription eye drops in their room which poses an immediate health and safety risk to residents in care.
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Type A
10/25/2021
Section Cited

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87303(e) Maintenance and Operation
(2) Faucets used by residents... Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. The requirement is not met as evidenced by:
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Based on observation, the licensee failed to comply with the section cited above as the hot water temperature in the common hallway bathroom measured at 129.2 degrees F. which poses an immediate 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
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)
Page: 3 of 7
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
11/05/2021
Section Cited

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87465 (a) Incidental Medical and Dental Care (5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Based on observation, the licensee failed to comply with the section cited above as two out of three residents had medications that were not administered as prescribed which poses an immediate health risk to residents in care.
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Type B
11/05/2021
Section Cited

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§1569.69 (a)(2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training...
This requirement is not met as evidenced by:
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Based on record review, the licensee failed to comply with the section cited above as S1 did not have proof of completing the initial medication training 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
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)
Page: 4 of 7
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
10/25/2021
Section Cited

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87555 General Food Service Requirements(b)(23)All readily perishable foods..capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
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Based on observation, the licensee failed to comply with the section cited above as LPA Lopez observed hot dogs, cheese, and chicken stored in open packages which poses a potential health risk to residents in care.
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Type A
10/26/2021
Section Cited

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87608 Postural Supports
(5) (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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Based on observation, the licensee failed to comply with the section cited above as R2 and R3 were observed to have full bed rail and there is no record of R2 & R3 having an order from hospice 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
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)
Page: 5 of 7
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 B
11/05/2021
Section Cited

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87705 Care of Persons with Dementia(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Based on record review, the licensee failed to comply with the section cited above as one resident with dementia (R2) has a medical assessment older than on year which poses a potential health and safety risk to R2 in care.
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Type B
11/01/2021
Section Cited

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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff,..., if any, 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 review, the licensee failed to comply with the section cited above as one resident (R1) out of three residents had an appraisal older than one year 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
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)
Page: 6 of 7
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 B
11/01/2021
Section Cited

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87465 Incidental Medical and Dental Care (6) (A-F)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 record review, the licensee failed to comply with the section cited above as three out of three residents had incomplete centrally stored medication records which poses a potential health and safety risk to residents in care.
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Type B
11/01/2021
Section Cited

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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Based on interviews with staff, the licensee failed to comply with the section cited above as R2 had a fall which resulted in visable injury and it was not reported to CCL which poses a potential 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
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)
Page: 7 of 7