197609953-5-31-2023-29-AS-SURA-CSD2FJ-20230531172134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609953
Report Date: 05/31/2023
Date Signed: 05/31/2023 08:23:12 PM

Document Has Been Signed on 05/31/2023 08:23 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 LIVING		FACILITY NUMBER:	197609953
ADMINISTRATOR:	SIRANUSH ALVADZHYAN		FACILITY TYPE:	740
ADDRESS:	11749 WELBY WAY		TELEPHONE:	(818) 433-4432
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 5	DATE:	05/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:03 PM
MET WITH:	Siranush Alvadzhyan		TIME COMPLETED:	05:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required Annual inspection. Upon arrival, the LPA was greeted by staff, and explained the reason for the visit. The staff contacted the Administrator Siranush Alvadzhyan and they arrived shortly thereafter.

The LPA and the Administrator toured the physical plant areas at 12:40 p.m. inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three residents’ rooms. There was a linen closet in the hallway with extra towels and linens. Washer and dryer were operational.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Hot water temperatures measured between 116.5 and 11.6.8 degrees Fahrenheit in the common and private restrooms.

KITCHEN: Kitchen appliances were in operable condition. At 1:27 p.m. The facility has a sufficient supply of perishable and non-perishable food All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 112.8 degrees Fahrenheit at 1:35 p.m.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed required postings in the common area. One (1) fire extinguisher was observed to be fully charged and purchased on 04/20/2023. Continue on LIC 809C…

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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 AGE ASSISTED LIVING	FACILITY NUMBER: 197609953
	VISIT DATE: 05/31/2023

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BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility has one (1) shed in the backyard that is utilized for additional storage.

RECORDS: Residents’ records review began at 3:00 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 4:00 p.m; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The audit revealed that one out of three prescription medication bottles contained more pills than the actual number stated in the prescription bottle. Per the Administrator, the staff transferred pills from a current prescription bottle to a newly received prescription bottle, consequently, the number of pills in the bottles audited did not reflect the amount of pills per the new filled prescription.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control.

The LPAs obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Staff schedule

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/31/2023 08:23 PM - It Cannot Be Edited

Created By: Sandra Urena On 05/31/2023 at 04:37 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 AGE ASSISTED LIVING	FACILITY NUMBER: 197609953
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in one out of three out of medication bottkes contained more pills than prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee agrees to contract with a credentialed entity to conduct staff training on handling of the medication, medication bottles, and will email a copy of the training materials, sign in sheet, and the name, address and phone number of the credential entity. Licensee will email proof of tratining to LPA .

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Sandra Urena

LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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