197610390-5-16-2024-31-AS-JGTN-D5BQHQ-20240516121130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610390
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:15:07 PM

Document Has Been Signed on 05/16/2024 12:15 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOLDEN AGE SENIOR LIVING		FACILITY NUMBER:	197610390
ADMINISTRATOR/ DIRECTOR:	SARGSYAN, HASMIK		FACILITY TYPE:	740
ADDRESS:	7720 DENIVELLE ROAD		TELEPHONE:	(818) 939-7373
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY: 6		CENSUS: 5	DATE:	05/16/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:28 AM
MET WITH:	Hasmik Sargsyan - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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	Licensing Program Analyst (LPA) Gary Tan conducted a Pre-Licensing Inspection with the Administrator Hasmik Sargsyan The applicant is "Hay Multigroup Inc.,". A fire clearance was approved on 03/21/24 for six (6) non-ambulatory residents, one (1) of which may be bedridden on Room #3. The applicant has an approved hospice waiver for six (6) residents. The facility has a total of five (5) bedrooms and two (2) bathrooms. One of the room is designated for staff use only. The facility is a one storey building on the hill with the garage underneath. There is also a lift located just outside the garage for non-ambulatory and wheelchair bound resident. A tour of the physical plant was initiated at approximately 8:45 AM and the following was observed: KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of perishable and nonperishable food. Knives were observed locked in a kitchen drawer. Cleaning supplies and other toxins will be stored in the cabinet in the bedroom hallway which was locked during visit. BEDROOMS: There are four (4) bedrooms designated for client's use, two (2) shared and two (2) private. The applicant furnished the resident bedrooms with beds, night stand, chairs, dressers, bedding and linen. The bedrooms have sufficient lighting and storage. BATHROOMS: The facility has two (2) shared bathrooms for clients' use. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at a range of 111.2°F to 115.4°F. LAUNDRY ROOM: The laundry room is located in the garage. Laundry detergents and other cleaning agents were kept in the garage which was locked during visit. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN AGE SENIOR LIVING	FACILITY NUMBER: 197610390
	VISIT DATE: 05/16/2024

NARRATIVE

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(continued from LIC 809)

COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and side tables. The living room area was furnished with a television, a coffee table and sofas to sit the capacity of the facility. There were no visible immediate hazards. Cleaning supplies and chemicals are stored and locked in the garage below. There is a working telephone line and internet accessible to residents. Dual smoke/carbon monoxide alarms were tested and observed to be operable. Fire extinguisher is located in the kitchen and last bought on 03/21/24.

MEDICATIONS: The medication cabinet is located in the staff room and observed to be locked. A complete first aid kit is located in staff room.

Staff/Resident Records: Staff and resident records will be kept in the locked cabinet inside the staff room.

SURROUNDING GROUNDS: The stairs, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The front yard of the facility has a covered patio and backyard furniture to accommodate the residents. The Garage is attached to the house underground, locked and inaccessible to residents. The garage is currently being used as Laundry area, PPE, tools and old equipment storage. There is no body of water in the facility.

Component III was conducted with Licensee representative Andranik Khunkayan his wife Jenny Movsesian and the Administrator. No deficiencies were observed during visit..

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to take additional resident until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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