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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603100
Report Date: 03/12/2024
Date Signed: 10/01/2024 03:48:26 PM

Document Has Been Signed on 10/01/2024 03:48 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: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:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Emma Topadzuikyan, LicenseeTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rosaura Valenzuela, Leizl De La Cera, Milena Khurshudyan and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced subsequent Case Management visit in conjunction with complaint control number 31-AS-202403109588. The purpose of this Case Management visit is to issue citations for the deficiencies that were observed during the course of the complaint investigation that is not directly related to the complaint. LPAs and LPM met with the Licensee Emma Topadzuikyan and explained the reason for the visit.

During the investigation, LPAs observed the following:

1) R1 has dementia and the last time that they were medically assessed was in 2019.

2) Hospice records are incomplete for R1 and for Resident #2 (R2)

3) R2's facility file is incomplete

4) Incident reports for both R1 and R2 were not submitted to the Licensing Department

5) Hospice information was incomplete for both R1 and R2

6) Lack of Administrator qualifications

Pursuant to the California Code of Regulations, Title 22, the following deficiencies were observed and
and cited during this visit.

Exit interview conducted and a copy of the report and citations were issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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Document Has Been Signed on 10/01/2024 03:48 PM - It Cannot Be Edited


Created By: Rosaura Valenzuela On 03/12/2024 at 10:20 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2024
Section Cited
CCR
87705(c)(5)

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87705(c)(5) Care of Persons with Dementia-Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually both of which shall include a reassessment of the resident's dementia care needs.
This requirement was not met as
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The Licensee shall submit in writing to the Department by 3/26/2024 how they will ensure that all residents with dementia are medically assessed annually and reappraised annually or when a change in condition has been observed.
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evidenced by:
Based on records review, the Licensee did not have a resident with dementia annually medically assessed. R1's last medical assessment was conducted in 2019. This posses a potential health and safety risk to residents in care.
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Type B
03/26/2024
Section Cited
CCR87633(h)(3)

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87633(h)(3) Hospice Care of Terminally Ill Residents (h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record (3) A copy of the written certification statement of the resident's terminal illness from the medical
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The licensee shall submit in writing by 3/26/24 to Licensing Office, how they will ensure that residents in hospice have complete hospice records.
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director of hospice...
This requirement was not met as evidenced by:
The licensee did not provide the Department representative with this documentation. This poses a potential health and safety risk to residents in care.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


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Document Has Been Signed on 10/01/2024 03:48 PM - It Cannot Be Edited


Created By: Rosaura Valenzuela On 03/12/2024 at 11:27 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2024
Section Cited
CCR
87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to the licensing agency staff.
This requirement was not met as evidenced
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The Licensee shall submit in writing by 3/26/24 to the Department how they will ensure that all resident files are complete.
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by:
The Licensee did not present to Licensing agent complete resident records for R2. This poses a potential health and safety risk to residents in care.
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Type B
03/26/2024
Section Cited
CCR87211(a)(1)(B)

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87211(a)(B) Reporting Requirements-(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency for (B) any serious injury as determined by the attending physician and occurring while the resident is
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The Licensee shall submit in writing by 3/26/24, how they ensure that any serious incident reports and hospice notifications are submitted to licensing in a timely manner.
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under facility supervision.
This requirement was not met as evidenced by: The Licensee did not notify the Department that residents had entered hospice care and did not submit incident reports for residents. This poses a potential health and safety risk for residents in care.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


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Document Has Been Signed on 10/01/2024 03:48 PM - It Cannot Be Edited


Created By: Rosaura Valenzuela On 03/12/2024 at 11:39 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2024
Section Cited
CCR
87405(d)(1)(2)

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87405(d)(1)(2) Administrator Qualifications and Duties-The Administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). (2) Knowledge of the ability to conform to the applicable laws, rules, and regulations...
This requirement was not met as evidenced
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The administrator will enroll and take more administrator courses and provide proof of enrollment to CCLD by 3/26/24.
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by: Licensee did not ensure that the Administrator has enough knowledge to comply with Title 22 Regulations. Based on interviews and record review, the facility is not in compliance with Title 22 Regulations. This poses a potential health and safety risk to residents in care.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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