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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609953
Report Date: 05/05/2025
Date Signed: 05/05/2025 02:50:54 PM

Document Has Been Signed on 05/05/2025 02:50 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLDEN AGE ASSISTED LIVINGFACILITY NUMBER:
197609953
ADMINISTRATOR/
DIRECTOR:		SIRANUSH ALVADZHYANFACILITY TYPE:
740
ADDRESS:11749 WELBY WAYTELEPHONE:
(818) 433-4432
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 4DATE:
05/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Siranush AlvadzhyanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two (2) staff and four (4) residents present. The LPA was greeted by staff who then contacted the Administrator via telephone. The Administrator, Siranush Alvadzhyan arrived at approximately 11:00 a.m. and at this time, the reason for the visit was explained. Entrance interview conducted.

Starting at 11:03 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 11:10 a.m. Knives and sharps were observed in locked metal containers on the kitchen counter. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be new and fully charged with a purchase date of 04/30/2025.

Report Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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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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 AGE ASSISTED LIVING
FACILITY NUMBER: 197609953
VISIT DATE: 05/05/2025
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Report Continued from LIC 809...

Required postings were observed throughout the common space. Activities were observed in the living room and dining room. There is a working telephone on premises. The LPA observed a locked closet in the hallway with additional clean linens, towels, and personal hygiene items. Laundry room was observed locked and inaccessible at the time of the visit. Cleaning supplies and detergents were observed inaccessible to residents in care at the time of the visit.

RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 11:05 a.m., the hot water temperature was measured in both bathroom and they measured within the required range of 105 – 120 degrees Fahrenheit.

BEDROOMS: There are three (3) bedrooms for resident use. All bedrooms are designated as double occupancy / shared rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

BACKYARD: The backyard has a covered patio area with patio furniture for resident use. The LPA observed two (2) locked sheds for storage purposes. All passageways were observed to be clear of any obstructions. The facility is gated. No bodies of water noted at the time of the visit.

RECORDS: The LPA reviewed Resident Records at 11:30 a.m. and Personnel Records at 12:05 p.m.

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
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 AGE ASSISTED LIVING
FACILITY NUMBER: 197609953
VISIT DATE: 05/05/2025
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Report Continued from LIC 809C...

Six (6) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order.

Administrator’s certificate is valid until 03/19/2026

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one conducted on 04/28/2025.

MEDICATIONS: Medications review began at approximately 01:00 p.m. The medications are locked in a cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. A copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
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