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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609828
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:27:32 PM

Document Has Been Signed on 08/16/2022 12:27 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Jenick MausakhanianTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Jenick Mausakhanian for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. On the day of the visit Jenick Mausakhanian was designated by the Administrator to sign and accept this report. A tour of the physical plant was conducted at 10:00am and the following was noted:
There is one entrance being utilized at the facility, there are required posters at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Hand washing, coughing etiquette, physical distancing and other necessary signs are posted in the bathroom and throughout the facility. The facility has enough PPE supplies. The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory with a hospice waiver for two (02). The facility is currently occupying five (05) non-ambulatory residents of which one (01) is under hospice care. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. Living and dining room furniture were also checked. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 77°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen, observed to be full and purchased 08/16/2022.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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, 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: 08/16/2022
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 117.2°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents.


Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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