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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 11/10/2021
Date Signed: 11/10/2021 04:35:35 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: 5DATE:
11/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Oganes John Duymalyan and Tsisana "Anna" MikiaTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Emily Peraldi and Kelly Dulek arrived to this location today for the purpose of conducting a Case Management – Deficiencies visit. At 10:24AM, LPAs met with caregiver Tsisana “Anna” Mikia and explained reason for visit. Licensee arrived at the facility at 12:12PM.

Between 10:32AM – 11:03AM, LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards. At 11:22AM, LPAs reviewed resident records and medication.

At 11:22AM, LPAs observed PRN medications for 5 of 5 residents – Resident #1 (R1) has 1 PRN medication, Resident #2 (R2) has 3 total PRN medications, Resident #3 (R3) has 3 PRN medications, Resident #4 (R4) has 3 PRN medications, and Resident #5 (R5) has 1 PRN medication. However, staff interview revealed that Tylenol is the only PRN medication administered and it is administered for pain. Licensee stated that PRNs can be administered if they are requested, however, there is no statement on file from the physician stating if the residents can determine the need for a PRN medication and no record of PRN medications administered.

At 11:25AM, there were no files present for 2 (R4 and R5) of 5 residents residing in the facility.

At 11:30AM, LPAs observed there were no centrally stored medication records for 5 of 5 residents.

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. Civil Penalties assessed in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report, civil penalties and appeal rights were provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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 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: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2021
Section Cited

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87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication...there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file...all of the following information:
This requirement is not met as evidenced by:
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Based on observation, interview, and record review, there are no PRN orders in any of the 5 resident files, which poses an immediate health risk to residents in care.
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staff and will provide proof of training to CCL by 11/17/2021. Licensee will also provide proof of PRN authorization by 11/17/2021.
Type A
11/17/2021
Section Cited

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87506 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 was not met as evidenced by:
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Based on record review, there were no files present at the facility for 2 (R4 and R5) out of 5 residents present in the facility, 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021
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: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/12/2021
Section Cited

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...
This requirement is not met as evidenced by:
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Based on observation and record review, the facility did not have current centrally stored medication records for 5 of 5 residents present at the facility, 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3