197609953-5-11-2026-29-AS-ECOZ-DTZ23L-20260511170231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609953
Report Date: 05/11/2026
Date Signed: 05/11/2026 05:02:43 PM

Document Has Been Signed on 05/11/2026 05:02 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOLDEN AGE ASSISTED LIVING		FACILITY NUMBER:	197609953
ADMINISTRATOR/ DIRECTOR:	SIRANUSH ALVADZHYAN		FACILITY TYPE:	740
ADDRESS:	11749 WELBY WAY		TELEPHONE:	(818) 433-4432
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	05/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Siranush Alvadzhyan		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were three (3) staff and six (6) residents present. The LPA was greeted by staff and the LPA explained the reason for the visit. Staff contacted the Administrator via telephone. The Administrators, Siranush Alvadzhyan and Mary Mkrtchyan arrived shortly thereafter and the reason for the visit was explained. Entrance interview conducted.

Starting at 01:15 p.m., the LPA along with staff, 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. 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 03/04/2026. 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. 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.

Report will continue on LIC809-C, 2ND PAGE.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN AGE ASSISTED LIVING	FACILITY NUMBER: 197609953
	VISIT DATE: 05/11/2026

NARRATIVE

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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 01:39 p.m., the hot water temperature was measured in both bathroom and they measured 113.7 and 113.5 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. The LPA Observed Resident 1 (R1) in room 1 and Resident (R2) in room 3 with bed rails extending the entire length of the bed.

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.

INTERVIEWS: The LPA conducted six resident interviews, no immediate concerns were voiced at this time.

RECORDS: The LPA reviewed Records at 2:00 p.m. The LPA reviewed five (5) out of six (6) resident files 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. The LPA observed that R1 and R2 were not receiving hospice services. File review also revealed that three (3) out of five (5) residents did not have updated appraisal/needs and service plans. The LPA reviewed five (5) out of seven (7) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, and criminal record clearances. The LPA checked the Guardian website and the Licensing Information System Facility Personnel Report Summary and observed that Staff 1 (S1) who was present during today's visit was not associated to the facility. Per S1 and the LIC500 they have been working at the facility since April 2026.

Due to time constraints the LPA will return at a later date to complete the annual.

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.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/11/2026 05:02 PM - It Cannot Be Edited

Created By: Esther Cortez On 05/11/2026 at 04:22 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: 05/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in one (1) out of five (5) staff members observed at the facility did not have a transfer of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2026
	Plan of Correction
1 2 3 4	Administrator stated she will associate the staff member on guardian today or submit the Criminal Record Exemption Transfer Reequest LIC9188 to the Regional Office and submit proof to LPA by due date.

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.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/11/2026 05:02 PM - It Cannot Be Edited

Created By: Esther Cortez On 05/11/2026 at 04:55 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: 05/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in two residents that were observed with full bed rail without currently receiving hospice services which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2026
	Plan of Correction
1 2 3 4	Administrator agreed to removed the full bed rail, replace with 1/2 bed rail and submit proof to LPA by due date.

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.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC809 (FAS) - (06/04)

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