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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609953
Report Date: 10/04/2021
Date Signed: 10/04/2021 04:19:18 PM

Document Has Been Signed on 10/04/2021 04:19 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLDEN AGE ASSISTED LIVINGFACILITY NUMBER:
197609953
ADMINISTRATOR:SIRANUSH ALVADZHYANFACILITY TYPE:
740
ADDRESS:11749 WELBY WAYTELEPHONE:
(818) 433-4432
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 4DATE:
10/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Siranush Alvadzhyan, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies inspection visit at the facility today due to deficiencies observed during the initial visit of complaint control #29-AS-20211001095530.

At 9:03 a.m., the LPA observed one (1) lighter on the outdoor seating area, accessible to residents in care. Lighter was secured at the time of observation. At 9:04 a.m., the LPA observed an outdoor shed, containing Detergent, Soap, Hot Shot Bug Killer, Comet, Easy Off, Ant & Roach Killer, Pinesol floor cleaner, and Round Up spray, among other chemicals, was unlocked and accessible to residents in care. Staff secured it at the time of observation. At 2:44 p.m., the Administrator did not provide the LPA the required documentation for one (1) out of six (6) resident files Hospice care plan. At 2:44 p.m., the Administrator also did not provide the LPA the required documentation for one (1) out of six (6) resident files Home Health care plan.



Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Civil penalty assessed for repeat violation.

Exit interview conducted, today's reports and appeal rights were issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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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Document Has Been Signed on 10/04/2021 04:19 PM - It Cannot Be Edited


Created By: Salia Walker On 10/04/2021 at 02:04 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: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2021
Section Cited
CCR
87705(f)(1)(2)

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87705 Care of Persons with Dementia:(f)The following shall be stored inaccessible to residents with dementia:(1) Knives, matches.. (2) Over-the-counter medication.. toxic substances such as.. cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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During today's visit, lighter and outdoor shed was locked and secured. The Licensee has agreed to do the following:
1. Provide training on section 87705(f)(1),(2) to staff, and submit proof of training to CCL by 10/11/2021.
Civil penalty assessed for repeat violation on 05/27/2021.
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Based on observation, the licensee did not comply with the section cited above, as the LPA observed one (1) lighter on the outdoor patio seating and an unlocked outdoor shed containing cleaning supplies and disinfectants, which poses an immediate health and safety rights risk to persons 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2021 04:19 PM - It Cannot Be Edited


Created By: Salia Walker On 10/04/2021 at 02:46 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: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2021
Section Cited
CCR
87506(d)(1)(I)

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Resident Records:(d)All resident records shall..(1)Licensing representatives shall not remove..records..(I)Any other records containing.. health-related information..(e)Original records.. shall be retained for a minimum of three (3) years..
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
1. Submit required Home Health records to CCLD by 10/07/2021.
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Based on observation, the licensee did not comply with the section cited above, as one (1) out of six (6) resident files did not contain the resident Home Health care plan, which poses a potential health, and safety risk to persons in care.
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Type B
10/04/2021
Section Cited
CCR87633(b)

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87633(b) Hospice Care of Terminally Ill Residents: (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
1. Submit required Hospice records to CCLD by 10/07/2021.
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Based on observation, the licensee did not comply with the section cited above, as one (1) out of six (6) resident files did not contain the resident Hospice care plan, which poses a potential health, and safety risk to persons 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2021


LIC809 (FAS) - (06/04)
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