195850632-5-21-2025-29-AS-CYEE-DGW4P5-20250521191611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850632
Report Date: 05/21/2025
Date Signed: 05/21/2025 07:16:42 PM

Document Has Been Signed on 05/21/2025 07:16 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOLDEN YEARS ASSISTANCE LIVING, INC		FACILITY NUMBER:	195850632
ADMINISTRATOR/ DIRECTOR:	KARAPETYAN, KARINE		FACILITY TYPE:	740
ADDRESS:	15013 MARLIN PL		TELEPHONE:	(606) 600-0006
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 0	DATE:	05/21/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Laura Aceituno Garcia, Applicant		TIME VISIT/ INSPECTION COMPLETED:	07:25 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 Christine Yee conducted an announced Prelicensing and Component III visit using the complete CARE Inspection Tool. LPA Yee met with Laura Aceituno Garcia, Applicant/Licensee and Ovsanna Khayalyn, Corporate Officer. The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 resident bedrooms and 2 full bathrooms. The facility is located behind the home with the address of 15015 Marlin Place. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #2 is designated for bedridden use. The following was observed on today's visit: the living room and dining room is furnished with the appropriate furniture and sitting. Located in the living room is a desk, a filing cabinet for staff and resident files and the facility telephone. The facility phone number is (747)264-1052. the kitchen is equipped with a refrigerator, stove, microwave and coffee maker. Located in the kitchen is the only fire extinguisher purchased on 2/11/25. Dish washing detergent and cleaning solutions are stored in a locked cabinet under the sink. Knives are stored in a locked kitchen drawer and medications will be stored in a locked kitchen cabinet. Sufficient non-perishables foods were observed for a minimum of 7 days but could be supplement with more protein foods. Perishables foods for a minimum of 2 days will be purchased prior to accepting the first resident. All 3 bedrooms are furnished with 2 twin beds, 2 night stands, 2 lamps, 2 covered trash cans,

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS ASSISTANCE LIVING, INC	FACILITY NUMBER: 195850632
	VISIT DATE: 05/21/2025

NARRATIVE

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1 chair and a built in closet.
sufficient bed linens and towels were observed in the closet of the 3 bedrooms except for blankets. A total of 5 blankets were observed. Additional blankets need to be purchased to allow for changing.
the common bathroom located by bedroom #3 is equipped with a walk in shower, a toilet and a single sink. A slip resistant mat and grab bars were observed in the walk in shower and by the toilet. The water temperature was tested and read 123.3 degrees Fahrenheit.
The staff bathroom located closest to the living room is equipped with a bath tub and a shower, a toilet and a sink. A slip resistant mat and no grab bars were not observed in the shower or by the toilet. Water temperature was tested and read 122.7 degrees Fahrenheit. Located inside the bathroom is the washer and dryer. Additional hygiene products, cleaning solutions, laundry detergent were observed stored in a cabinet under the sink and in a mounted cabinet. Recommendation was made to lock the cabinets to ensure that the items would be inaccessible to the residents if staff forgot to lock the bathroom door or if the bathroom was needed in an emergency.
The hard wired smoke detectors located in the 3 bedrooms and the only combination smoke/carbon monoxide detector located in the hallway were tested and were operational.
A first aid kit with the required tweezer, scissors, thermometer and supplies was observed. A first aid manual was also observed.
the outside area was observed with a covered gazebo with a padded bench, a table with 4 chairs, a rattan bench and a chair with a glass table. Trash cans were observed to be tightly sealed. The outside areas were observed to be clean and well maintained.

The following deficiencies need to be corrected prior to licensure:

the thermostat for the water heater needs to be adjusted and the water temperature in the two bathrooms needs to be within a range of 105-120 degrees Fahrenheit.
3 additional chairs need to be provided in the 3 bedrooms
7 twin blankets need to be purchased to allow for changing
Grab bars need to be installed in the staff bathroom for emergency resident use.
locks need to be placed on the cabinets that contain the cleaning supplies, laundry detergent and hygiene products in the staff bathroom to allow for emergency resident use.
provide a dedicated internet device for resident use with a device usage policy

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS ASSISTANCE LIVING, INC	FACILITY NUMBER: 195850632
	VISIT DATE: 05/21/2025

NARRATIVE

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purchase additional non-perishable foods and proteins to supplement the food currently in the facility.

The following will be completed upon licensure of the facility:

purchase liability insurance with limits of a $1 million dollars per occurrence and $3 million total aggregate.
purchase perishable foods for a minimum of 2 days prior to accepting the first resident and to be maintained on the premises.
Files will be created for all residents, staff and any volunteers

Component III was also conducted with Laura Aceituno Garcia, Applicant and Ovsanna Khayalyn, Corporate Officer on today's visit.

Applicant will notify LPA Yee once all the corrections have been completed and evidence of corrections are provided.

Exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

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