198603100-7-27-2022-28-AS-MGFS-CGQU33-20220727151253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603100
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:13:31 PM

Document Has Been Signed on 07/27/2022 03:13 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	NO PLACE LIKE HOME FOR GOLDEN AGES 2 LLC		FACILITY NUMBER:	198603100
ADMINISTRATOR:	TOPADZUIKYAN, EMMA		FACILITY TYPE:	740
ADDRESS:	1444 WESTERN AVE		TELEPHONE:	(818) 245-6614
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91201
CAPACITY:	5	CENSUS: 3	DATE:	07/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:54 PM
MET WITH:	Maria Sereno - Caregiver		TIME COMPLETED:	03:30 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	Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit with focus on infection control domain, medication and food review. LPA met with Maria Sereno caregiver and explained the reason for the visit. LPA inquired caregiver about notifying administrator, caregiver indicated it was not necessary to notify administrator/licensee regarding visit. The facility is licensed to serve 5 non-ambulatory residents ages between 60 and over and a hospice waiver for 2 hospice residents. Facility is a one story single home in a residential area and consists of the following: 3 bedrooms, 3 resident bathrooms, 1 staff bathroom, garage, gated pool with pool house. Backyard has an area with tables/ umbrellas for shade. Facility has a living room, kitchen/dining room and front porch. Pool house is inaccessible to residents. LPA Flores conducted a tour of the facility with Maria Sereno Caregiver and observed the following: Screening area was recommended to be place by entry way rather than in the middle of the living room to prevent from visitors entering the facility prior screening process. Staff were observed without face covering. Living room has a cover fireplace, sufficient sitting area, and signs posted. Medication cabinet is located in the living room, PPE supplies were observed in a cabinet and is not sufficient for at least 30 days. Kitchen was observed and cabinets under the sink labeled knives and cleaning supplies were observed unlock during the visit. Facility has sufficient food supplies for at least 2 days worth of perishables and 7 days of non-perishables. Residents rooms were observed as follows: Room #3 (R3) has all required furniture and bedding, 3 out of 4 small light bulbs were not working and sufficient lighting is not provided. Room #1(R1) and Room #2(R2) have all required furniture, bedding, and sufficient lighting. Bathroom #1(B1) was observed and shower floor was observed damage and in disrepair, bathroom #2(B2) had bleach solution on top of the toilet and under the sink unlocked cabinet, water temperature was measured as follow: B1 at 133.5 degrees F., B2 tested at 133.2 degrees F., and Bathroom #3(B3) tested at 133.3 degrees F., which is not within the required 105-120 degrees F. (CONTINUED LIC 809C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 2 LLC	FACILITY NUMBER: 198603100
	VISIT DATE: 07/27/2022

NARRATIVE

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Staff bathroom and resident bathrooms are missing proper hand wash signs. Smoke/Carbon Monoxide detectors were observed, tested, and in working condition. Fired extinguisher was observed last reviewed on 7/26/21. Backyard was observed and grass was over growth, boxes, and a gas tank were piled on the wall of the grass area, and large toys were hanging from the pool gate. Medication and files were review for 3 residents. Staff files were not reviewed ans staff stated staff files are not available at the facility.

Deficiencies were noted on LIC 809D per Title 22 Regulations and Technical advisories will be given for infection control guidance.

Exit interview was conducted with Maria Sereno caregiver and a copy of this report, LIC 809D, and appeal rights was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 10

Document Has Been Signed on 07/27/2022 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 2 LLC	FACILITY NUMBER: 198603100
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 in B1 water temperature tested at 133.5, B2 water temperature tested at 133.2 and B3 water temperature tested at 133.3 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2022
	Plan of Correction
1 2 3 4	Licensee will ensure water temperature is within the required 105 - 120 degrees F., at all times will certify on LIC 9098 by POC due date 7/28/22.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 in LPA observed knives and cleaning solutions cabinet unlocked, bleach solution on top of toilet in B2 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2022
	Plan of Correction
1 2 3 4	Licensee will ensure that all sharps, and cleaning supplies are unaccessible to the residents at all times and will certify in LIC 9098 by POC date 7/28/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 3 of 10

Document Has Been Signed on 07/27/2022 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 2 LLC	FACILITY NUMBER: 198603100
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 in B1 shower floor was observed damaged and in disrepair, lightbulbs out in R1, boxes in the backyard piled, large toys hanging by the pool gate, and grass was umkept, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2022
	Plan of Correction
1 2 3 4	Licensee will ensure facility is maintain clean and in good repair at all times. Licensee will submit pictures of repairs and cleaning to the department by POC date 8/3/22.

Type B

Section Cited

CCR

87412(f)

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 in staff files were not available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2022
	Plan of Correction
1 2 3 4	Licensee will ensure files are at the facility at all times and will provide the department a statement to certify the above by POC date 8/3/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 4 of 10