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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608579
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:09:52 PM

Document Has Been Signed on 04/14/2022 12:09 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 AGESFACILITY NUMBER:
197608579
ADMINISTRATOR:EMMA TOPADZHIKYANFACILITY TYPE:
740
ADDRESS:1459 WESTERN AVENUETELEPHONE:
(818) 245-6799
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff Willeta FraniTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with the staff Willeta Frani who assisted with the visit. Reason for the visit was explained. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. The facility is licensed for six (6) residents over the age of 60, 5 non-ambulatory, one of which can be bedridden. The facility was granted on hospice waiver for 2 residents.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. LPA inspected the interior and the exterior of the facility with staff including but not limited to living room, dining room, activity room, kitchen, six (6) resident bedrooms, three (3) bathrooms, laundry area, attached two car garage and outside covered/patio area with chairs. Front and back yards are well maintained. LPA observed drained gated locked pool in backyard. All indoor and outdoor passageways are free of obstruction.

Bathrooms and bedrooms were clean and in good repair. All residents bedrooms were toured. Each bedroom were furnished with required furniture and had sufficient closet space. Three bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 115.3 - 116.7 degrees which is within the required 105 - 120 degrees. LPA observed fire extinguisher in activity room which was fully charged. Carbon monoxide detectors were observed operational. First-aid Kit is complete and located in the activity room. There is a locked cabinet for medications in the kitchen.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579
VISIT DATE: 04/14/2022
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The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. Kitchen knives and sharps are stored in a locked drawer in the kitchen. The common areas including the living room, dining room and activity room are clean and have the required furniture. The facility has cameras in the common areas only.

LPA reviewed residents files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. Residents' medications were reviewed. Medications are documented properly and stored appropriately.


Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit.

A copy of the report was provided to the Staff Willeta Frani.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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