<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609828
Report Date: 01/05/2022
Date Signed: 01/05/2022 01:14:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2021 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20211021112548
FACILITY NAME:NO PLACE LIKE HOME FOR GOLDEN AGES 3, LLCFACILITY NUMBER:
197609828
ADMINISTRATOR:MELIK, DIANEFACILITY TYPE:
740
ADDRESS:3754 MONTROSE AVE.TELEPHONE:
(747) 255-7188
CITY:GLENDALESTATE: CAZIP CODE:
91214
CAPACITY:6CENSUS: 5DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jenick Mausakhanian, StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction

Staff did not inform resident's authorized person of illness.

Staff did not meet resident's diapering needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint visit to the facility to deliver the findings for the above noted allegations. LPA met with Staff Jenick Mausakanian and explained the purpose of the visit.

It was alleged that Resident #1 (R1) was illegally evicted from the facility. During the investigation on 10/26/21 at 11:26am, staff interviews were initiated. Staff interviews revealed that R1 was not evicted. Staff told LPA that R1 was sent to the E.R. due to a prohibitive health condition. R1 had two deep tissue injuries on the chest area covered with necrotic skin, that were secreting pus. LPA was able to confirm this information upon review of hospital records on 11/02/2021 at approximately 1:30pm. Based on interview and record review it was concluded that R1 was transferred to the hospital due to a developing prohibited health condition. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

It was reported that staff did not inform R1's authorized person of illness. To investigate this allegation, LPA
See-9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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 31-AS-20211021112548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 3, LLC
FACILITY NUMBER: 197609828
VISIT DATE: 01/05/2022
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
26
27
28
29
30
31
32
interviewed staff on 10/26/2021 at 11:26pm. Interviews revealed that staff did inform R1's authorized person of illness via text. LPA was able to confirm this information when a Special Incident Report (SIR) was reviewed. In addition, on 10/21/21. LPA interviewed the reporting party by phone and interview revealed that licensee had contacted reporting party by text, but since their phone was turned off, they did not see it in a timely fashion.

Based on interviews and record review, there is no relevant information to verify the allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

It was alleged that staff did not meet resident's diapering needs causing redness and a rash on R1's buttocks. To investigate this allegation, LPA interviewed staff. Staff interviews revealed that all residents have a bell that rings to notify staff that they need their diaper to be changed. According to staff, R1 always liked to have a dry diaper and was changed immediately when wet. Staff also indicated that they did not observe any redness or a rash on R1's bottom. On 10/26/2021 at 12pm, LPA Valenzuela spoke with other residents and they had no concerns regarding their incontinent care provided at the facility.

Based on the information revealed from interviews, there is insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2