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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603100
Report Date: 05/19/2021
Date Signed: 05/19/2021 04:17:53 PM

Document Has Been Signed on 05/19/2021 04:17 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NO PLACE LIKE HOME FOR GOLDEN AGES 2 LLCFACILITY NUMBER:
198603100
ADMINISTRATOR:TOPADZUIKYAN, EMMAFACILITY TYPE:
740
ADDRESS:1444 WESTERN AVETELEPHONE:
(818) 245-6614
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 5CENSUS: 5DATE:
05/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:24 PM
MET WITH:Emma Todapzuikyan - AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst(s) Mary Flores and Luis Mora conducted a complaint investigation at the facility on 5/19/21 met with Emma Todapzuikyan - facility administrator and explained the reason for the visit.

During the course of the investigation it was discovered staff #2(S2), and staff #3(S3) providing care and supervision to residents in care were not listed in the licensing information system (LIS) roster for the facility. LPA(s) verified staff clearance with regional office via phone call. Although, S2 and S3 have a background clearance on record, S2 and S3 are not associated to the facility.

Per, Title 22, Division 6, Chapter 8, Article 6. Criminal Record Clearance; (e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 1569.17(b).

Immediate Civil Penalties were assess. Per Title 22, Division 6 ,Chapter 8 (e) Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department. Civil Penalties were assess at $1000.

Exit interview was conducted with Emma Todapzuikyan - Administrator and a copy of the report, LIC9099D, LIC421BG, and appeal rights was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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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Document Has Been Signed on 05/19/2021 04:17 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/19/2021 at 03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 2 LLC
FACILITY NUMBER: 198603100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2021
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidence by:
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Administrator will submit proof of transfer request form, staff ID, and print of proof of association for staff #2 and staff #3 via email by 5/20/21.
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Based on observation and documents reviewed facility did not ensure a criminal background transfer request for S2 and S3 was obtain which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
*Civil Penalties were asses at $1000.*
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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.
SUPERVISOR'S NAME:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2021


LIC809 (FAS) - (06/04)
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