197610448-8-15-2023-31-AS-MCAA-CUQTHP-20230815144503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610448
Report Date: 08/15/2023
Date Signed: 08/15/2023 02:45:39 PM

Document Has Been Signed on 08/15/2023 02:45 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:	GOLDEN YEARS SENIOR LIVING INC		FACILITY NUMBER:	197610448
ADMINISTRATOR:	HARUTYUNYAN, VAHAGN		FACILITY TYPE:	740
ADDRESS:	12501 BRADFORD PL		TELEPHONE:	(818) 568-6448
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	08/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Vahagn Harutyunyan, Gevorg Yanukyan		TIME COMPLETED:	03:00 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) Christopher Alemoh and Michael Cava conducted a Component III and Pre-Licensing Inspection with the applicant representative, Gevorg Yankyan and administrator, Vahagn Harutyunyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on May 30, 2023. A fire clearance was approved on June 16, 2023 for six (6), of which five (5) may be non-ambulatory and one (1) bedridden, for a total capacity of six. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual and interconnected. The facility has two fire extinguishers, located in the kitchen and hallway near the front entrance. They were last charged on June 16, 2023. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives and utensils were observed locked in a kitchen drawer. There was also a sufficient amount of kitchenware for resident use. BEDROOMS: The facility has a total of five (5) bedrooms. Four (4) rooms are designated for client use. Bedroom #1 and #4 are shared, with bedroom #4 having a bedridden fire clearance (per STD 850). Bedrooms #2 and #3 are private rooms. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. All four bedrooms have sufficient lighting and closet space. Bedroom #5 is designated for staff. BATHROOMS: The facility has three (3) bathrooms. Two bathroom are for resident use. One bathroom is for staff. Bathrooms designated for residents were observed to have the proper fixtures, grab bars, and non-skid mats. Staff bathroom will be locked and inaccessible to the residents. The hot water delivered in the resident bathrooms measured at 106 degrees.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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

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: GOLDEN YEARS SENIOR LIVING INC	FACILITY NUMBER: 197610448
	VISIT DATE: 08/15/2023

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

COMMON AREAS: These included the living room/activity room and dining room. The living room/activity room was equipped with two couches, two tables, and a working telephone. There is a fireplace with a screen and a glass slide. It is non-operational. According to the applicant and administrator, the gas is turned off. There were no fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards. The facility has two fire doors installed. One at the dining room and one by the front entrance which leads to resident rooms.

LAUNDRY ROOM: The laundry room is located by staff room (room #5). The laundry room will be kept locked at all times. Laundry detergents and cleaning supplies will be maintained in the laundry room.

MEDICATIONS: The medications will be kept in a kitchen cabinet, which has a magnetic locking mechanism.

STAFF ROOM: Staff room will be utilized as a workstation and break room. It is located by the kitchen next to the laundry area. Staff and resident records will be maintained in the staff room where there is shelves and shelves in place. Staff room will be locked and inaccessible to residents at all times.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space for leisure and activities. There is a swimming pool that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2