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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609953
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:06:44 PM

Document Has Been Signed on 04/05/2022 03:06 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLDEN AGE ASSISTED LIVINGFACILITY NUMBER:
197609953
ADMINISTRATOR:SIRANUSH ALVADZHYANFACILITY TYPE:
740
ADDRESS:11749 WELBY WAYTELEPHONE:
(818) 433-4432
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 3DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Karine KhachatryanTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, the LPA was greeted by staff, and the LPA explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with staff at 2:23 p.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Between 2:28 p.m. and 2:31 p.m., hot water temperatures measured between 113.2 and 113.8 degrees Fahrenheit in the common and private restrooms.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 118.5 degrees Fahrenheit at 2:34 p.m.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in dining room area. One (1) fire extinguisher was observed to be fully charged and purchased on 5/27/21.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility has one (1) shed in the backyard that utilized for additional storage.

Continue on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN AGE ASSISTED LIVING
FACILITY NUMBER: 197609953
VISIT DATE: 04/05/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with staff regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

No deficiencies cited at this time. Exit interview conducted, and a copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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