195850126-11-10-2021-29-AS-EPEI-C8N2LG-20211110162931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850126
Report Date: 11/10/2021
Date Signed: 11/10/2021 04:30:43 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: 5	DATE:	11/10/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Oganes Duymalyan and Tsisana “Anna” Mikia		TIME COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Emily Peraldi and Kelly Dulek arrived to this location today for the purpose of conducting a Plan Of Correction / Case Management (POC) visit to follow up on the Plan of Correction citations issued during the case management and annual visit conducted on 10/25/2021 by LPA Kasandra Lopez and Teresa Camara. At 10:24 a.m. LPAs met with caregiver Tsisana “Anna” Mikia and explained reason for visit. Licensee arrived at the facility at 12:12 p.m. Licensee left the facility at 3:40 p.m., and authorized Anna to sign the report. A Notice of Operating in Violation of Law (NOV) was issued to Akhtar "Ellie" Roshanaeian during a visit on 10/25/2021. This location was previously licensed as 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, on 09/09/2021, the licensed corporation underwent a 100% change in ownership reflecting Ms. Roshanaeian as the only managing member, effectively replacing Oganes Duymalyan. On 10/26/2021, the corporation underwent another 100% change of ownership back to Oganes Duymalyan. On 11/04/2021, Oganes Duymalyan signed a lease with the landlord of the property. Oganes Duymalyan now has control of property. Plan of Correction met. A discussion was held with Oganes Duymalyan regarding the submission of plan of corrections (POCs) from visits on 10/25/2021. On 10/25/2021, the facility was cited for having centrally stored medications accessible to residents. Medications were secured during the visit on 10/25/2021. On 11/10/2021 at 10:37 a.m., LPAs observed medications in resident room one (1) and in the hallway, LPAs observed Calmoseptine accessible to residents. On 11/10/2021 at 10:58 a.m., LPAs observed medications on top of a filing cabinet. The Proof of Correction was due on 11/05/2021. As of today, the plan of correction is not met; civil penalty issued for failure to correct. Civil Penalties will be issued for period 11/06/2021-11/10/2021, which is a total of five (5) days, at $100.00 per day. Civil Penalties will accrue until plan of correction is met. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
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)

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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: 11/10/2021

NARRATIVE

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On 10/25/2021, the facility was cited for medications not being administered as prescribed. During today’s visit, LPAs conducted a medication review and LPAs observed medications not administered as prescribed. Resident One (R1)'s medication Losartan Potassium 50 MG TA 30 QTY, one tablet daily was prescribed on 10/07/2021 and facility records indicate the medication was started on 10/07/2021, but the bottle still has one (1) pill inside. The Proof of Correction was due on 11/05/2021. As of today, the plan of correction is not met; civil penalty issued for failure to correct. Civil Penalties will be issued for period 11/06/2021-11/10/2021, which is a total of five (5) days, at $100.00 per day. Civil Penalties will accrue until plan of correction is met

On 10/25/2021, the facility was cited for failure to have proof of completed initial medication training for Staff One (S1). The Plan of Correction was due on 11/05/2021. As of today, the plan of correction is not met; civil penalty issued for failure to correct. Civil Penalties will be issued for period 11/06/2021-11/10/2021, which is a total of five (5) days, at $100.00 per day. Civil Penalties will accrue until plan of correction is met.

On 10/25/2021, the facility was cited for having a medical assessment older than a year for the resident with dementia. The Plan of Correction was due on 11/05/2021. As of today, the plan of correction is not met; civil penalty issued for failure to correct. Civil Penalties will be issued for period 11/06/2021-11/10/2021, which is a total of five (5) days, at $100.00 per day. Civil Penalties will accrue until plan of correction is met.

Civil penalties issued in the amount of $2,000.00

Exit interview conducted. A copy of the report was issued via email. Civil penalties and related appeal rights issued via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
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

LIC809 (FAS) - (06/04)

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