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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603100
Report Date: 07/23/2021
Date Signed: 07/23/2021 04:35:04 PM

Document Has Been Signed on 07/23/2021 04:35 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: 4DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Willeta FraniTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPAs) Alma Gonzalez and Luis Mora conducted an unannounced annual visit at the facility. LPAs met with Willeta Frani, caregiver and explained the reason for the visit. LPA spoke to Administrator, Emma Topadzuikyan who stated that she would not be able to assist LPAs with the visit but that Caregiver Frani would be able to assist LPAs.

The facility is licensed to serve 5 non-ambulatory residents ages between 60 and over and a hospice waiver for 2 hospice residents. Facility is a one story single home that consists of the following: 3 bedrooms, 4 bathrooms, garage, gated pool with pool house. Backyard has an area with tables/ umbrellas for shade. Facility has a living/dining room, kitchen. Pool house is inaccessible to resident's and residents favor sitting out in the front shaded porch versus sitting in the backyard.

LPAs conducted a tour of the facility along with Caregiver Frani and observed the following:

Facility's Kitchen has sufficient food supplies for 2 days of perishables, and 7 days of non-perishables; LPA observed fresh fruit, frozen meats, vegetables, can foods and additional emergency food supplies and water. Sharps/knives were kept unlocked in the stove oven. Caregiver was asked to remove the sharps and place them in a locked a cabinet. Cleaning supplies were locked under the sink. LPA observed and reviewed first aid kit located in a kitchen cabinet and had all the required items. File cabinet with clients medication is located in the facility living room. At the time of the tour the file cabinet containing resident's medication was not locked. Bedrooms #1, #2, #3 have proper lighting, and furniture; beds have all the required bedding. Resident's bathrooms were observed to have skid mats, handle grab bars, client's hygiene products kept in cabinet, and water temperature was tested at 138.9 degrees F. LPAs observed linen and towels. Smoke detectors and carbon monoxide detector(s) were observed and tested. Fire extinguisher was observed in kitchen and had not been serviced and did not have a tag indicating when it was last serviced.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 198603100
VISIT DATE: 07/23/2021
NARRATIVE
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There is sufficient lighting throughout the facility. The grounds are well groomed and there were no hazards observed. The front exterior of the facility is clear of debris with steps leading to the facility entrance. Trash containers have covered lids. There are no security bars nor weapons on the premises.

LPAs observed that required documents are posted as mandated. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed hand sanitizer stations throughout the facility. LPA observed facility staff wearing masks, and required postings throughout the facility. The residents temperature's are checked and logged twice a day in the AM and PM. Facility has an adequate amount of PPE and facility has enough PPE for 30 days.

As LPA's were completing annual visit, a live cockroach was observed crawling n the facility kitchen window which is located near were the kitchen table is located.

Based on Title 22, Chapter 8 Division 6 deficiencies will be noted on LIC809D.



Exit interview was conducted with Willeta Frani and a copy of this report, LIC 809D, LIC 9102, and appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/23/2021 04:35 PM - It Cannot Be Edited


Created By: Alma Gonzalez On 07/23/2021 at 01:38 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: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as Water temperature read 138.9 which is not within Title 22 regulations which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Administrator/ Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator/ Licensee to submit a faxed or mailed copy of POC by due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as all facility residents medications were observed in an unlocked file cabinet located in the facility living room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Administrator/ Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator/ Licensee to submit a faxed or mailed copy of POC by due date.
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:Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/23/2021 04:35 PM - It Cannot Be Edited


Created By: Alma Gonzalez On 07/23/2021 at 02:06 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: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that knives were observed in the stove oven unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Administrator/ Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator/ Licensee to submit a faxed or mailed copy of POC by due date.
Type A
Section Cited
CCR
87203
Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that fire extinguisher had not been serviced and did not have a tab indicating when it was last serviced which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Administrator/ Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator/ Licensee to submit a faxed or mailed copy of POC by due date.
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:Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/23/2021 04:35 PM - It Cannot Be Edited


Created By: Alma Gonzalez On 07/23/2021 at 02:09 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: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Good Service Requirements
(b) The following food service requirements shall apply:
(27) All kitchens shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the licensee did not comply with the section cited above as when LPA's were completing annual visit, a live cockroach was observed crawling n the facility kitchen window which is located near were the kitchen table is located which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2021
Plan of Correction
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Administrator/ Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator/ Licensee to submit a faxed or mailed copy of POC by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
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