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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850632
Report Date: 05/14/2026
Date Signed: 05/14/2026 06:15:32 PM

Document Has Been Signed on 05/14/2026 06:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLDEN YEARS ASSISTANCE LIVING, INCFACILITY NUMBER:
195850632
ADMINISTRATOR/
DIRECTOR:		KARAPETYAN, KARINEFACILITY TYPE:
740
ADDRESS:15013 MARLIN PLTELEPHONE:
(606) 600-0006
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
05/14/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Ovsanna Khayalyn, Corporate OfficerTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to deficiencies observed during a visit to the facility today. LPA Yee was let into the home by Stella Gevorkoka, Staff. Staff contacted Ovsanna Khayalyn, Corporate Officer and she arrived at 11:13am to conduct the visit. The reason for today's visit was provided.
  • Upon arrival at the facility LPA Yee was looking for the trash can and opened the cabinet located under the kitchen sink. Observed in the cabinet were cleaning solutions such as 409,Comet, Palmolive dish soap, Tide, laundry detergent, Ziploc freezer bags and 3 bottles of Mazola cooking oil, all stored together. LPA Yee observed that the cabinet was left unlocked and staff was away from the kitchen. Yee advised Staff that the cabinet must be kept locked at all times.
  • A tour of the facility was also conducted on today's visit and LPA Yee observed that Resident #1 and Resident #6's beds were equipped with full bed rails and they are not on hospice. Written physician's orders also do not specify the need for full bed rails.
  • Resident #5's bed is equipped with a half bed rail and there is no written physician's order on file for the use of the half rail.



Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights discussed and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/14/2026 06:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/14/2026 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS ASSISTANCE LIVING, INC
FACILITY NUMBER: 195850632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2026
Section Cited
CCR
87309(a)(1)

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Storage Space and Access Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,.... and other similar items which could pose a danger to residents are in which could pose a danger to residents are in locked storage and are not
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Licensee will ensure that Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. Licensee will review the items stored in the cabinet under the kitchen sink and any other areas that is used for storage
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 ...1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. Cooking oils were stored together with cleaning solutions/Detergents
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of cleaning solutions and laundry detergent and relocate any food that is stored together with the cleaning solutions, laundry detergent and any poisons. Submit evidence that the deficiency has been corrected by 5/15/26
Type B
05/21/2026
Section Cited
CCR87608(a)(5)B)

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 Postural Supports. 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. Based on observation and record review, Resident #1 and Resident #6 were observed
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Licensee will either remove the full bedrails for Resident #1 and Resident #6 and replace with 1/2 bed rails or submit a written request for the use of full bed rails and all suppporting documents for the use of full bed rails for consideration by 5/21/26
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 using full bed rails and both are not on hospice. The doctor's orders also do not specify the use of full bed rails
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2026 06:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/14/2026 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS ASSISTANCE LIVING, INC
FACILITY NUMBER: 195850632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2026
Section Cited
CCR
87608(a)(3)

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Postural Supports: Based on the individual's preadmission appraisal, and subsequent changes to that appraisal.....Postural supports may be used under the following conditions. A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record
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Licensee will ensure that residents who have a need postural supports, obtain a written physiican's order prior to its use and maintain in the resident's file. Licensee will remove the 1/2 bedrail or obtain a written physician's order prior to use.
*****THE 1/2 BED RAIL WAS REMOVED
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he licensing agency shall be authorized to require other additional documentation if needed to verify the order. Per record review and observation, Resident #5 had 1/2 bedrails mounted on the bed and did not have any written order from a physician
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RESIDENT #5' BED DURING THE VISIT*****

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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
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