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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609828
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:24:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
03/08/2024 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20240308160649
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:
03/12/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Emma Topadzuikyan, LicenseeTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Licensee did not provide resident with copy of admissison agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced visit for the above noted allegation. LPA and LPM met with Licensee Emma Topadzuikyan and explained the reason for the visit.

It was reported that Licensee did not provide a resident with a copy of the admission agreement. To investigate this investigation on 3/12/24, between 3:50pm and 4:00pm facility records for Resident #1 (R1) were requested. Facility records for R1 were not provided to Licensing Agents because they were not created. Between 4:00pm and 4:15pm, staff interviews were initiated. Staff #1 (S1) was interviewed and revealed that R1 never signed an admission agreement because they did not want to sign it.

Based on interviews, there is sufficient information to verify this allegtion. Thus, this allegation is SUBSTANTIATED at this time.
No health and safety issues were noted at the time of this visit. Exit interview conducted and a copy of the report was issued.





Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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 3
Control Number 31-AS-20240308160649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 3, LLC
FACILITY NUMBER: 197609828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2024
Section Cited
CCR
87507(a)
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87507(a) Admission Agreements (a) The licensee shall complete an individual written admission agreement with each resident and that resident's responsible person or conservator, is any.
This requirement was not met as evidenced by:
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The Licensee will submit in writing to the Department by 3/26/24, how they will ensure that all residents in care have a signed admission agreement.
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Based on interviews the Licensee admitted that R1 did not have or sign an admission agreement. This poses a potential health and safety risks to 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3