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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609953
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:15:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20211001095530
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:
05/27/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Siranush Alvadzhyan, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced to deliver the findings for the above allegations. The LPA met with Administrator Siranush Alvadzhyan, and explained the reason for the visit.

On 10/01/2021, the Department received a complaint of neglect/lack of care and supervision, resulting in Resident #1 (R1) sustaining pressure injurie(s) while in care. During the initial visit conducted on 10/04/2021, LPA Salia Walker conducted a physical plant tour at 8:59 a.m. The LPA also conducted interviews with the facility residents, the administrator, staff, and reviewed and obtained copies of documents pertinent to the investigation. The LPA determined further investigation was needed at that time.

Continue on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 29-AS-20211001095530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2022
NARRATIVE
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Regarding the allegation, ‘Resident sustained pressure injury while in care,’ it is alleged that R1 sustained pressure injurie(s) while in care. According to the complainant, on 9/6/2021, R1 was seen by a Home Health Medical Team (HHMT) and had a small opened wound. Then on 9/21/2021, the HHMT saw R1, and the images showed an “unstageable” pressure injury (most severe).

During the investigation, the LPA attempted to contact R1 to obtain additional information. However, all contact numbers provided were no longer in service. The investigation revealed that R1 was admitted to this facility on 9/10/2021. A review of the initial Physician’s Report, dated 9/9/2021, indicated that R1 did not have a history of skin breakdown. The reporting party was able to interview R1, who informed them that there were only two little ladies working the facility, who were physically unable to move or reposition R1.

On 9/28/2021, R1 went to the Hospital for a Radiology appointment. During the appointment, R1 reported having a painful pressure injury on R1’s sacrum. The nurse then requested that Radiology send R1 to the Emergency Room (ER) to get care “for stage 4 pressure ulcer.” Record review revealed that upon admission to the ER, R1 was assessed by a wound care RN, in which the nurse documented “Type of Wound: pressure injury. Location: Sacro coccyx. Stage: Unstageable. Measurements(cm): 11x11 x0.1 cm (uneven edges) ...” Records review revealed that R1 was discharged from the hospital on 10/13/2021 with palliative care to a Skilled Nurse Facility (SNF). Record review revealed that R1’s home health admission date was 9/13/2021.

An interview with the administrator revealed that R1 was only at the facility for 19 days; R1 went to a radiology appointment and was then transferred to a SNF. According to the administrator, they were unaware of the severity of R1’s skin integrity. The administrator stated that the discharging hospital did not notify the facility of any wound upon placement. The administrator stated the facility staff reported to the administrator (date unknown) that R1 had an open wound on their ‘buttocks’ area. The administrator also stated that they “never saw the wound on R1.” However, it is the administrator’s responsibility to observe and monitor any wounds/pressure injuries for any changes. According to the administrator, the facility then called the discharging hospital and requested that they send a wound specialist. Additionally, the administrator stated that the Home Health nurse would call and provide an update on R1’s progress. Allegedly, however, the Home Health nurse did not disclose R1’s wound stages.

Continue on LIC9099C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20211001095530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2022
NARRATIVE
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However, it is the administrator’s responsibility to follow-up and ask those questions from the home health nurse. The administrator disclosed that the Home Health nurse advised via telephone, prior to the appointment on 9/28/21, that R1 was going to check themselves “into the ER to have the wound checked.” The LPA made numerous attempts to speak with the HH nurse to ask whether or not the nurse informed the facility staff of the wound stage; however, the nurse did not return the call.

Staff interviews revealed that staff were able to move/reposition R1. Although the staff stated that R1 ‘was heavy,’ staff ‘always repositioned’ R1. Staff confirmed that R1 was a two-person assist, and repositioning would be conducted ‘often’ as they were ‘always in pain’; and, R1’s diapers had to be changed. Staff interviews further revealed that staff discovered the pressure injury on R1’s ‘bottom,’ and advised the Administrator (date unknown). Staff #1 (S1) stated that they discovered the ‘wound on his lower back,’ the first day R1 came to the facility (09/10/21). S1 also stated that there was an individual that accompanied R1 to the facility, who took photos, then ‘made calls.’ S1 stated that after that individual made the calls, nurses from home health began to visit R1 for wound care.

The discharge documents did not note any wound on R1 upon discharge. The administrator stated she had no knowledge of R1 having a pressure injury upon admission to the facility; or, of the stage of the pressure injury. The facility staff failed to ensure that R1 was regularly observed for any changes; and, that appropriate assistance was provided when the observation revealed unmet needs. The staff also failed to document R1’s medical changes and notify the appropriate parties. R1’s Reappraisal was not updated to reflect the change of condition that R1’s pressure injury was worsening. Therefore, the licensee representative did not have a level of care meeting to discuss the change of condition with the resident, staff, and the home health agency. In addition, as a result, the licensee representative was retaining a resident with a prohibited health condition and failed to request an exception to retain that individual with a prohibited health condition.

Based on the investigation, there is sufficient evidence to support the claim that due to neglect and lack of care and supervision, R1 sustained a pressure injury while in care. Therefore, this allegation is deemed Substantiated at this time.

Continue on LIC9099C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20211001095530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2022
NARRATIVE
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Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit interview conducted. A copy of the report was issue, along with appeal rights.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20211001095530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2022
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Condition: Persons who require health series for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly. (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD.
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Based on interviews and record reviews, the licensee did not fail to comply with the section cited above. The Licensee retained a resident with a prohibited health condition between 9/21/21 and 9/28/21, which posed an immediate health and safety risk to residents in care.
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Type A
06/01/2022
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes… and that appropriate assistance is provided when such observation reveals unmet needs… documented and brought to the attention of the.. physician…
This requirement is not met as evidenced by:
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Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD.

Immediate civil penalty of $500 is assessed.
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Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to communicate R1’s worsening pressure injury/wound with R1’s physician which attributed to R1’s stage 4 pressure injuries while in care, which posed an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20211001095530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2022
Section Cited
CCR
87463(c)
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87463(c) Reappraisals(c): The licensee shall arrange a meeting with… a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition…

This requirement is not met as evidenced by:
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Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD.
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Based on records review and interviews, the licensee did not comply with the section cited above as the facility failed to have a level of care meeting to discuss R1’s change of condition when R1’s pressure injury worsened, which posed a potential health and safety risk to residents in care.
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Type B
06/03/2022
Section Cited
CCR
87463(a)(3)
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Reappraisals (a)The pre-admission appraisal shall be updated...as frequently as necessary to note significant changes… (3) Any illness, injury…or change in the health care needs... Prohibited Health Conditions.

This requirement is not met as evidenced by:
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Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD.
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Based on records review and interviews, the licensee did not comply with the section cited above as the facility failed to update R1’s appraisal with change of condition when R1’s pressure injury worsened, which posed a potential health and safety risk to residents 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20211001095530

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:
05/27/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Siranush Alvadzhyan, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff are unable to meet resident's care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced to deliver the findings for the above allegations. The LPA met with Administrator Siranush Alvadzhyan, and explained the reason for the visit.

On 10/01/2021, the Department received a complaint alleging that because staff were unable to meet the needs of Resident #1 (R1), R1 sustained pressure injurie(s) while in care. During the initial visit conducted on 10/04/2021, LPA Salia Walker conducted a physical plant tour at 8:59 a.m. The LPA also conducted interviews with the facility residents, the administrator, staff, and reviewed and obtained copies of documents pertinent to the investigation. The LPA determined further investigation was needed at that time.

Continue on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20211001095530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2022
NARRATIVE
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Regarding the allegation, ‘Facility staff are unable to meet resident's care needs,’ it is alleged that R1 was only at the facility for a month, and they could not handle R1, but accepted R1 from a hospital placement. It is also alleged the facility staff could not move or reposition R1 during the duration of stay.

During the investigation, LPA Walker conducted interviews with the administrator, and facility staff. The LPA also attempted to contact R1 to obtain additional information. However, all contact numbers provided were no longer in service.

Interviews with the administrator revealed that facility staff reposition residents that require repositioning ‘as needed.’ The Administrator stated that Resident #1 (R1) was repositioned approximately every hour. Interviews with the administrator also revealed that all facility staff are trained in repositioning. Interviews with facility staff revealed tthat staff were able to move/reposition R1. Although the staff stated that R1 ‘was heavy,’ staff ‘always repositioned’ R1. Staff confirmed that R1 was a two-person assist, and repositioning would be conducted ‘often’ as they were ‘always in pain’; and, R1’s diapers had to be changed.

Based on conducted interviews and a record review, R1 was placed on Home Health to receive wound treatment upon staff reporting to the administrator that R1 had an open wound. Therefore, there is insufficient evidence to support the allegation ‘Facility staff are unable to meet resident's care needs.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8