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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609953
Report Date: 03/02/2022
Date Signed: 03/04/2022 08:07:01 AM

Document Has Been Signed on 03/04/2022 08:07 AM - 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:
03/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Siranush AlvadzhyanTIME COMPLETED:
03:00 PM
NARRATIVE
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On 03/02/2022, at 1:35 p.m., Licensing Program Analyst (LPA) Sandra Urena, conducted an unannounced Case Management-Deficiency visit to address the deficiencies noted during complaint control # 29-AS-20210813133851, conducted on 08/18/2021. LPA Urena spoke with administrator Siranush Alvadzhyan, and explained the reason for the visit.

At 2:30 pm on 08/18/2021, the LPA conducted residents’ file review, and the LPA found that the facility failed to ensure that a resident’s file for Resident #1 (R1) was completed prior to the time of admission. LPA interviewed Staff # 1(S1), and S1 stated that Resident R1 arrived in the middle of the night, and didn’t have time to create a resident’s file. The R1 resided at the facility from 07/18/2021 to 07/21/2021. The licensee did not create a file for R1 with all the required documents prior to admission, and during R1’ s stay at the facility. The following documents were missing:

· Resident Appraisal RCFE (LIC 603A)
.· Appraisal Need and Services Plan, when applicable (LIC 625).
· Physician’s Report for RCFE (LIC 602A) Residential Care for the Elderly,
· Medical Assessment Section 87569 and General Requirements for Allowable Health Conditions,
· (Section 87702.1).
· Identification and Emergency Information (LIC 601).
· Current admission agreement with authorized signatures, Admission Agreement Guide for RCFE
· (LIC 604A).
· Evidence of receipt of personal rights information by resident and/or authorized representative
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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: 03/02/2022
NARRATIVE
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  • Personal Rights (LIC 613C).
· Reports of safeguards for resident cash resources including supporting receipts of expenditures.
· Record of Client’s/Resident’s Safeguarded Cash Resources (LIC 405) and record of each resident’s
personal property and/or valuables entrusted to facility, Client/Resident Personal Property and
Valuables (LIC 621).

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Deficiencies were issued today. Exit interview was conducted. Today's report was reviewed and signed by Siranush Alvadzhyan. Citations and and Appeal Rights were reviewed and provided. A copy of the report was issued via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2022 08:07 AM - It Cannot Be Edited


Created By: Sandra Urena On 03/02/2022 at 12:39 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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
87506(a)(d)

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87506-Residents Records a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met as evidence by
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Licensee agrees to review Regulation 87506 (a)-(d) to ensure that no resident is admitted, and resides at the facility without a full file Resident Record. A self certification letter attesting to reviewing the regulation should be submitted to the licensing office by 03/04/2022.
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Base on the records review, the facility failed to ensure that a resident’s file for R1 was created prior to the time of admission to the facility, and while R1 resided in the facility, which poses a health and safety, personal 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:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


LIC809 (FAS) - (06/04)
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