197609953-5-17-2023-29-AS-JAPL-CS7P3U-20230526105807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609953
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:36:04 PM

Unsubstantiated

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
10/19/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20221019135455

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: 4	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Siranush Alvadzhyan		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility restricted visitation
Facility failed to notifiy residents' responsible party of change of condition
Facility failed to treat resident with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced subsequent complaint visit at the facility regarding the above allegations. The LPA met with Administrator Siranush Alvadzhyan and explained the reason for the visit.

During the visit on 10/27/2022, the LPA conducted a facility tour at 10:00 a.m., interviewed staff at 10:05 a.m. and 10:25 a.m., reviewed and collected documents at 10:50 a.m. ad interviewed residents at 11:05 a.m., 11:15 a.m., 11:27 a.m. and 11:28 a.m. On 11/14/2022, the LPA returned to the facility to resolve the complaint allegations, requested additional information and conducted interview. On 5/17/2023 the LPA conducted a plant tour, interviewed residents and delivered the findings.

**Continued on LIC 9099-C**

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221019135455

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: 05/17/2023

NARRATIVE

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Regarding the allegation: Facility restricted visitation

It was alleged that the facility restricted visitation by asking Responsible Parties (RP) not to visit. Interviews with staff, residents, and responsible parties of residents who reside at this location confirmed that at one time there were visitation restrictions due to COVID-19 however, facility did not impede from residents having visitation. Families were told that they can visit as they wish and that leaving a resident for a few days to acclimate without family visitation was not discouraged and left at the discretion of the family. The facility has set up a patio area for visitation outside the facility, meaning families could visit and see a resident in the patio if necessary. An interview with the complainant did not confirm claims that visitation was denied by the facility and that while the RP visited Resident #1 (R1) every day, they would often sit outside in the patio after dropping things off. The administrator confirmed that a conversation was had with the RP about allowing the resident to acclimate to the facility without visitation, but it was not required, nor did it imply that they were not to be visited by the RP. Residents communicated minimal concerns in having reasonable visits with visitors. Resident interviews revealed no difficulties in speaking to or seeing their family and had not experienced any limitations outside of local restrictions. Staff denied claims that anyone has been restricted visitation and visitors are allowed.

Based on the information obtained, while this may or may not have happened there is insufficient evidence to support the claim that the ‘facility restricted visitation’. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility failed to notifiy residents' responsible party of change of condition

It was alleged that the facility failed to inform the responsible party (RP) of Resident #1 (R1s) change in medical condition. It was reported that R1’s family was not informed of R1 having a change in condition within the first few days of admission. Interviews conducted with RP, revealed that R1 was at a skilled nursing facility prior to their admission to this facility as R1 had fallen at their personal home and suffered a head injury. Facility files reviewed revealed that R1 fell on 10/4/2022, to which staff took R1’s vitals, applied an ice pack and reported that they seemed okay.

**Continued 9099-C**

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221019135455

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: 05/17/2023

NARRATIVE

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PAGE 3
The Administrator provided documentation confirming that R1s RP was informed of the changes. It was also discovered that R1’s RP had visited R1 at the facility on 10/5/2022 and at that time, R1 was sleeping but seemed strange, however still appeared okay. Additionally, R1’s family member had requested that facility staff monitor R1 and provide them with updates to which they did. On 10/6/2022 family visited R1 and noticed that R1 was not their usual self. However, staff indicated that R1 was only sleeping and was okay. Staff communicated that any changes to R1’s condition were communicated to the RP as they visited every day and were very active in R1’s care. Furthermore, interviews revealed that on 10/8/2022 R1 had a change in vitals and a decline in their condition at which time 911 was called and the RP was notified. The RP additionally requested R1 be sent to a religion specific hospital. Based on interviews and record review, while this may or may not have happened the Department does not have sufficient evidence to support the allegation of “facility failed to notify residents’ responsible party of change of condition”. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility failed to treat resident with dignity and respect

On the allegation of ‘facility failed to treat residents with dignity and respect’, the reporting party (RP)’s concern is that Resident #1 (R1) was screaming when touched or approached by staff and seemed terrified. To investigate the allegation the LPA’s conducted resident interviews and staff interviews. The residents’ interviews revealed that they feel respected and cared for here, and they are treated with dignity and respect. Resident interviews denied claims that they have ever been force fed, hurt or left unattended by staff. Residents’ interviews revealed that they have never witnessed staff treat residents inappropriately. Interviews with staff denied claims that residents have been has disrespected or failed to be treated with dignity and respect. Based on the information obtained through interviews, while this may or may not have happened there is insufficient evidence to support the allegation that ‘facility failed to treat residents with dignity and respect’. Therefore, this allegation is Unsubstantiated at this time.

No deficiencies cited at this time. A copy of this report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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