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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609828
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:19:56 PM


Document Has Been Signed on 03/12/2024 05:19 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:NO PLACE LIKE HOME FOR GOLDEN AGES 3, LLCFACILITY NUMBER:
197609828
ADMINISTRATOR:MELIK, DIANEFACILITY TYPE:
740
ADDRESS:3754 MONTROSE AVE.TELEPHONE:
(747) 255-7188
CITY:GLENDALESTATE: CAZIP CODE:
91214
CAPACITY:6CENSUS: 5DATE:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Emma Topadzuikyan, LicenseeTIME COMPLETED:
05:30 PM
NARRATIVE
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This case management visit was conducted in conjunction with complaint control number 31-AS-20240308160649 to address the deficiencies unrelated to the complaint allegations.

On 3/12/24 at 3:00pm, during complaint investigation LPA Valenzuela and LPM Margaryan were informed that the Licensee/Administrator does not have facility file for Resident #1 (R1).

No documents were available for Licensing agents to review.

Therefore, under Title 22 Regulations, the following deficiency was cited and recorded on LIC 809D.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 2


Document Has Been Signed on 03/12/2024 05:19 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 3, LLC
FACILITY NUMBER: 197609828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2024
Section Cited
CCR
87506(a)

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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
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The licensee will submit in writing to Licensing by 3/26/24, how they will ensure that all resident records are complete and readily available upon request to Licensing Agents.
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by:
Based on interviews, Licensee did not have any records for R1.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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