197610448-9-13-2024-31-AS-MCAA-D93T4U-20240913142430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610448
Report Date: 09/13/2024
Date Signed: 09/13/2024 02:24:36 PM

Document Has Been Signed on 09/13/2024 02:24 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:	VIKTORYA HAYRAPETYAN		FACILITY TYPE:	740
ADDRESS:	12501 BRADFORD PL		TELEPHONE:	(818) 568-6448
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 2	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Viktorya Hayrapetyan, Irene Plokhova		TIME COMPLETED:	02:30 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	In conjunction with a Pre-Licensing visit (see facility #197610603), Licensing Program Analyst (LPA) Michael Cava conducted a Required Annual Inspection of the facility. LPA met with administrators, Viktorya Hayrapetyan and Irene Plokhova, and advised them of the visit. The facility is a one story building. The smoke alarms and carbon monoxide are dual, hardwired and interconnected. There are two fire extinguishers. One is located in the kitchen, and the other is located in at the enclosed patio area. The charge date is March 4, 2024. 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. Rooms #1 and #4 are shared. Rooms #2 and #3 are private. Room #5 is currently designated for staff use, but has a fire clearance for Ambulatory only. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. All five bedrooms have sufficient lighting and closet space. 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 between 108 and 109 degrees.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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: GOLDEN YEARS SENIOR LIVING INC	FACILITY NUMBER: 197610448
	VISIT DATE: 09/13/2024

NARRATIVE

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COMMON AREAS: These included the living room and dining room areas. The living room room was equipped with a couch, love seat, chair table and television. There is a fireplace with a screen and a glass slide. It is non-operational. According to the administrators, the gas is shut off. There were no fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). The floors were mopped and clean. Passageways and hallways were clear of obstruction. The facility has three 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 is kept locked in a kitchen cabinet. LPA reviewed medications and medication records for proper storage and documentation.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms

GARAGE: The garage is attached to the home. Entry is at the kitchen. It requires a combination code to gain access. Garage will be used for storage space.

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.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there are no deficiencies observed during the visit. Exit Interview Conducted and a copy of this report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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