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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608579
Report Date: 05/18/2021
Date Signed: 05/18/2021 11:40:40 AM

Document Has Been Signed on 05/18/2021 11:40 AM - 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 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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Emma Topadzhikyan, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza initiated a Case Management-Deficiencies visit as a result of observations made when conducting complaint control #: 28-AS-20210514161456 investigation. The purpose of this visit was explained to Administrator Emma Topadzhikyan.

During the physical plant tour of the facility resident (R1's) bed was observed to have full rails. Per staff (S2) resident is not receiving hospice services. Administrator was interviewed and stated that R1 is not enrolled in hospice, but agreed to placing the resident in a hospital bed with full rails because family requested it due to fall risk. Administrator was advised to obtain a doctor's order for a half rails for R1's bed.

LPA requested to review R1's file [Physician Report, and Appraisals]. Documents did not state R1 is a hospice resident. Copies of ID and Emergency Information, Physician's Report, LIC 500 Personnel Report, and Register of Facility Residents were obtained.

Per Title 22, Division 6, Chapter 8 Article 11. Health-Related Services and Conditions deficiency is being cited. See LIC 809D.

Exit interview was conducted with Administrator Emma Topadzhikyan. A copy of the report an appeal rights were provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2021 11:40 AM - It Cannot Be Edited


Created By: Noemi Galarza On 05/18/2021 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
CCR
87608(a)(5)(B)

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87608(a)(5)(B). Postural Supports. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement was not met by evidence of:
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Administrator agreed to remove full size bed rails. Administrator will obtain a doctor's order for a 1/2 bed rail. Submit certification that full size bed rails will not be used, unless a resident is receiving hospice care, and proof of half rail doctor's order.

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Based on physical plant observation at 9:47 am LPA observed resident (R1's) bed had full rails. Resident is not receiving hospice care. Administrator verified R1 is not enrolled in hospice at this time. This poses an immediate health and safety risk to the residents in care.
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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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