197610357-1-11-2023-31-AS-MRUZ-CMYSQC-20230111130430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610357
Report Date: 01/11/2023
Date Signed: 01/11/2023 01:05:12 PM

Document Has Been Signed on 01/11/2023 01:05 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	RM GOLDEN CARE		FACILITY NUMBER:	197610357
ADMINISTRATOR:	SARGSYAN, MAYA		FACILITY TYPE:	740
ADDRESS:	9030 WHITAKER AVENUE		TELEPHONE:	(818) 486-6352
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 0	DATE:	01/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Maya Sargsyan		TIME COMPLETED:	01:20 PM

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On 1/11/2022, Licensing Program Analyst (LPA) Melissa Ruiz conducted an announced Pre-Licensing visit to this facility and met with applicant Maya Sargsyan. This is an initial application for a Residential Care Facility for the Elderly. A fire Clearance dated 12/2/2022 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in Room #4. Facility has applied for a hospice waiver for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

Facility has a fire extinguisher, with a date of purchase of 11/26/22. There is a functioning telephone on the premises. Emergency exit plan/sketch is posted on the living room wall with other posting requirements. There are (4) resident bedrooms. The common areas (living room, kitchen and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked cabinet in living area. Medications are centrally stored in a locked kitchen cabinet. The first aid kit is readily available. There are three (3) bathrooms in the facility. One (1) bathroom is designated for staff use only and the two (2) common bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to have closed tight fitting lids.

(CONT. on LIC809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RM GOLDEN CARE	FACILITY NUMBER: 197610357
	VISIT DATE: 01/11/2023

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The kitchen knives are stored in a drawer in the kitchen. The kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the laundry room that leads to the garage. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There are no bodies of water.

Component III was conducted with applicant.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted with Licensee Representative Peter Atoyan. A copy of this report was signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC809 (FAS) - (06/04)

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