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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609748
Report Date: 11/07/2022
Date Signed: 11/07/2022 12:22:00 PM


Document Has Been Signed on 11/07/2022 12:22 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GRANADA GOLDEN YEARSFACILITY NUMBER:
197609748
ADMINISTRATOR:ARUTYUNYAN, SEVAKFACILITY TYPE:
740
ADDRESS:17201 LAHEY STTELEPHONE:
(818) 535-9693
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 4DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Naira Alikhanyan/ StaffTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home in response to a notification that the facility toilet had not been functioning properly. The LPA was able to tour the home, interview staff, and interview residents.

LPA toured the home and observed that both facility toilets were functioning properly. Interview with staff and residents did confirm, that about 2 weeks ago the toilet had been clogged and it took a few days for the issue to be corrected. While touring room number 3, the LPA did observe that the floor boards in the room had been warped due to water damage for the blocked toilet. The door to room 3 will not close and the resident is unable to close the door properly.

Interviews with staff and residents also indicated that the facility is not allowing residents to flush used toilet paper in the toilet and are directing them to throw it in a trash can. Facility staff stated that residents are asked to do this as a precaution, so that the toilets will not overflow.

A review of the facility incident reports also indicated that a report was not submitted for the broken toilet or the repair.

The LPA was able to discuss the issues over the phone with the administrator.

Exit interview conducted, deficiencies cited and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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


Document Has Been Signed on 11/07/2022 12:22 PM - It Cannot Be Edited

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., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: GRANADA GOLDEN YEARS
FACILITY NUMBER: 197609748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited

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Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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The licensee did not allow residents to flush toilet paper in the toilet and had them throw it in the trash can, which posed an immediate health and safety risk to the residents in care
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Type B
11/09/2022
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing...within seven days of the occurrence of any events specified in
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The licensee did not submit an incident report regarding the broken toilet, which posed a potential health and safety risk to the 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/07/2022 12:22 PM - It Cannot Be Edited

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., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: GRANADA GOLDEN YEARS
FACILITY NUMBER: 197609748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Based on LPA observation, the licensee did fix a residents floor causing a resident to not be able to close the door, which poses a potential risk to the resident 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3