<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609953
Report Date: 05/27/2021
Date Signed: 05/27/2021 02:39:56 PM

Document Has Been Signed on 05/27/2021 02:39 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:
(323) 236-2336
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 3DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Siranush AlvadzhyanTIME COMPLETED:
02:42 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Kelly Dulek and Salia Walker arrived at the facility unannounced to conduct a required annual visit at 11:25 AM. This annual had a specific emphasis on infection control practices and procedures. The LPAs initially met with facility staff Karine Khachatryan and discussed the reason for the visit. Administrator Siranush Alvadzhyan arrived at the facility at 1:02PM.

The LPAs, along with facility staff Karine Khachatryan, toured the physical plant areas inside and outside at 11:28AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 3 (three) total resident bedrooms.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPAs observed sufficient amounts of soap and paper products in each restroom.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common area and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the common dining room and hallway. One fire extinguisher was observed to be fully charged and purchased on 2/14/2020.

The yard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. At 12:22PM, LPAs observed an outdoor shed, containing Hot Shot Bug Killer, Comet, Easy Off, Ant & Roach Killer, Fabuloso floor cleaner, and Round Up spray, among other chemicals, was unlocked and accessible to residents in care. At 12:23PM, LPAs observed 2 (two) lighters and 2 (two) packs of cigarettes on the outdoor seating area, accessible to residents in care.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 05/27/2021 02:39 PM - It Cannot Be Edited


Created By: Kelly Dulek On 05/27/2021 at 01:35 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: 05/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as LPAs observed cigarettes and lighters on the outdoor patio seating and an unlocked outdoor shed containing cleaning supplies and gardening supplies which poses an immediate safety rights risk to persons in care.
POC Due Date: 05/27/2021
Plan of Correction
1
2
3
4
During today's visit, a lock was placed on the outdoor shed and all accessible items were moved to a locked location. Administrator agreed to provide training on section 87705 and provide proof of training to CCL by 6/3/2021.
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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2021


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/27/2021 02:39 PM - It Cannot Be Edited


Created By: Kelly Dulek On 05/27/2021 at 01:35 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: 05/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 (one) out of 3 (three) total residents did not have a medical assessment on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2021
Plan of Correction
1
2
3
4
Administrator called the resident's responsible party during today's visit to request the physician's report be filled out and returned to the facility. Administrator agreed to send a copy of Resident #1 (R1)'s physicians report to CCL no later than POC 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 05/27/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

RECORD REVIEW: At 12:10PM, LPAs reviewed resident records for, but not limited, to the following: physician's report and needs and service appraisal. At 12:13PM, LPAs observed Resident #1 (R1) who according to the Administrator has a diagnosis of dementia, did not have a physician's report on file. R1 moved into the facility in June of 2020.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the facility staff regarding the facility’s infection control practices at 11:35AM. Upon entry, the facility has a central entry point for symptom screening. The LPAs observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.


The following recommendations were made:
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department
- Staff surveillance testing should be completed per PIN 20-38-ASC

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

Exit interview conducted, today's reports, appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6