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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610357
Report Date: 05/06/2024
Date Signed: 05/06/2024 03:11:45 PM

Document Has Been Signed on 05/06/2024 03:11 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RM GOLDEN CAREFACILITY NUMBER:
197610357
ADMINISTRATOR/
DIRECTOR:		SARGSYAN, MAYAFACILITY TYPE:
740
ADDRESS:9030 WHITAKER AVENUETELEPHONE:
(747) 308-1111
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 4DATE:
05/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Maya Avagyan- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda generated this report to address a deficiency observed during the course of a complaint investigation initiated today.

While reviewing client records, LPA observed Resident 1 (R1) to NOT have an physician's report and TB test. The rest of the residents has all completed proper paper work. LPA advised licensee that all residents taken in needs to have a complete paper work and TB test.


Report reviewed, signed, and delivered. Exit interview conducted, appeal rights issued, deficiency on LIC 809-D page.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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 2
Document Has Been Signed on 05/06/2024 03:11 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 05/06/2024 at 02:56 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RM GOLDEN CARE
FACILITY NUMBER: 197610357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2024
Section Cited
CCR
87458(a)

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Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 Physician's Report, to obtain the medical assessment.
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Licensee will acknowledge and sendbletter to LPA a letter that moving forward a MD report and TB test should be done.
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This requirement is not met as evidenced by; Based on interviews, facility did not have phsycian report which poses a potential health, safety and personal rights risk to resident in care.
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Type B
05/20/2024
Section Cited
CCR87458(a)(1)

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A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude.
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Licensee will acknowledge and sendbletter to LPA a letter that moving forward a MD report and TB test should be done.
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care of the person by the facility.
This requirement is not met as evidenced by; Based on interviews, facility did not have tuberculosis (TB) which poses a potential health, safety and personal rights risk to resident 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.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
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