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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608579
Report Date: 05/18/2021
Date Signed: 05/18/2021 11:33:01 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2021 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210514161456
FACILITY NAME:NO PLACE LIKE HOME FOR GOLDEN AGESFACILITY NUMBER:
197608579
ADMINISTRATOR:EMMA TOPADZHIKYANFACILITY TYPE:
740
ADDRESS:1459 WESTERN AVENUETELEPHONE:
(818) 245-6799
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY:6CENSUS: 4DATE:
05/18/2021
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Emma Topadzhikyan, AdministratorTIME COMPLETED:
10:53 AM
ALLEGATION(S):
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Staff not wearing face coverings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an Initial 10-Day complaint visit regarding the above allegation,The purpose of the visit was discussed with staff Rubina Nersesyen. Administrator Emma Topadzhikyan arrived shortly after.

The investigation consisted of the following: A physical plant tour was conducted, staff (S1- S5), resident (R1-R3) were interviewed. Resident (R4) was not interviewed due to cognitive impairment. Copies of LIC 500 Personnel Report and resident roster were obtained. At 9:11 am LPA entered the home. Two (2) staff were observed. Staff (S2) was not wearing a mask. Staff (S2) was explained the purpose of the visit and immediately put the mask on. Three (3) out three (3) residents stated staff wear masks when caring for them. Administrator stated staff always wear a mask when entering a resident's room or caring for residents. Staff (S2) stated that it always wears mask when helping residents or when there are visitors "but today I forgot it."

Based on observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code. An exit interview was conducted with Administrator Emma Topadzhikyan. A copy of the report an appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20210514161456
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 197608579
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2021
Section Cited
HSC
1569.50(a)(3)
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(a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
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Administrator agreed to ensure that facility is following California Dept of Public Health and CCLD requirements. Administrator will provide a written statement stating that facility staff were re-trained and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.
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This requirement was not met by evidence of: At 9:11 am, upon entry into the facility LPA observed staff (S2) not wearing a mask. S2 stated it always wears a mask when caring for residents, "but today I forgot". This poses a health and safety risk.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2