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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610479
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:11:47 PM

Document Has Been Signed on 12/04/2024 04:11 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLDEN YEARS BOARDING CAREFACILITY NUMBER:
197610479
ADMINISTRATOR/
DIRECTOR:
KHARATYAN, NINAFACILITY TYPE:
740
ADDRESS:20358 KESWICK STREETTELEPHONE:
(818) 245-2383
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 2DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Karina Kuliian - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 12/4/2024 an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the Caregiver Karina Kuliian, who granted access to the facility. LPA explained the reason for the visit. Shortly after the Administrator, Nina Kharatyan arrived and helped with physical plant tour and staff/residents files.

During today's visit, LPA conducted a physical plant walk through, at approximately 11:30am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.
The following was observed:

The facility is a single-story home and is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and one (1) bedridden for bedroom #4. Facility also has a hospice waiver for five (5) resident. There are four (4) bedrooms in the facility of which four (4) are designated for residents’ use. All bedrooms observed to be appropriately furnished. All bedrooms have appropriate lighting. There are two (2) bathrooms in the facility designated for both residents’ and staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 12:45 to be 118°F. Extra towels and linens were readily available. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination.
LPA observed facility alarms were functional on all exit doors.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 1:00pm they were tested and observed to be operational. The facility has one (1) fire extinguisher that was last purchased on December 4th, 2024.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GOLDEN YEARS BOARDING CARE
FACILITY NUMBER: 197610479
VISIT DATE: 12/04/2024
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KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored in a locked drawer inaccessible to residents in care. Extra emergency food was properly stored inside the storage cabinet. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 12:00pm to be 75°F. No obstructions and or tripping hazards throughout the facility found.

MEDICATION: LPA observed centrally stored medication, facility staff/resident files, and First Aid kit locked in the kitchen cabinet and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program. PRN medications have written orders from a physician. The facility serves residents with dementia and facility has trained staff to meet the needs of residents who are diagnosed with dementia. Potentially dangerous items are kept inaccessible to residents in care. Facility has 2 staff for AM shift and 1 awake caregiver for PM shift.

COMMON AREAS: LPA observed living room and a dining room that appeared generally clean and were properly furnished. Fireplace in the living room is properly fenced and blocked with armchair. No obstructions and or tripping hazards throughout the facility. Facility has land line, LPA checked its operational.

LAUNDRY ROOM: Laundry machines are located in the separate closed door area next to the dining room. LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care.



SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. Appropriate outdoor furniture, with covered shaded area was available for residents at the front and back area of the house. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water. There is no garage in the property.

FILE REVIEW: Between 12:45pm to 2:30pm, LPA reviewed records and files of two (2) residents and four (4) staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians.


Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GOLDEN YEARS BOARDING CARE
FACILITY NUMBER: 197610479
VISIT DATE: 12/04/2024
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A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances. There are no residents with prohibited conditions residing at the facility.
Facility also provides activities to the residents.
An emergency exit plan/sketch along with other posting requirements are posted on the wall in the living room.

Medications Review: At approximately 2:45pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with two (2) shifts.

LPA collected LIC500, LIC9020, copy of Administrator's certificate and Infection Control / Mitigation Plan and copy of Liability Insurance Certificate.

No deficiency cited on today’s visit.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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