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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603100
Report Date: 03/12/2024
Date Signed: 03/12/2024 02:56:15 PM

Document Has Been Signed on 03/12/2024 02:56 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:
01:20 PM
MET WITH:Emma Topadzuikyan, LicenseeTIME COMPLETED:
02:45 PM
NARRATIVE
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This Case Management is conducted in conjunction with complaint control number 31-AS-20240301091588 to address the issues unrelated to the complaint.

During the complaint investigation visits conducted on 3/06/24 and today 3/12/24 LPAs were informed that facility retains Resident #2 (R2) who developed Stage 4 Pressure injury while in care of the facility.

On 3/06/24, the Licensee/Administrator was interviewed and she verified that R2 was a long-term resident and had a history of developing pressure injuries.

Prior to this visit, LPA Valenzuela and LPM Margaryan contacted hospice agency to request Hospice records for R2. The records were e-mailed to the LPM Margaryan on 3/12/24 at the time of Licensing visit. A review of hospice records revealed that on or before 2/26/24, R2 developed pressure injuries. Stage 4 pressure injury on Right Buttock and sacrum. According to wound care records, between 2/28/24 and 3/11/24 R2's pressure injuries were not healing. The records also indicate that due to condition of the wounds' infection is suspected. Overall investigation regarding R2's pressure injuries revealed that although R2 is receiving hospice services and wound care is provided, R2's pressure injuries were not healing and may result in an infection.

Based on observation, interviews and record review, it was concluded that the facility retains the resident that developed prohibited health condition and require a higher level of care.

R2's health condition and other noted issues were discussed with the Licensee/Administrator and she was informed that at this time the facility is not in compliance with Title 22 Regulations.

The Licensee/Administrator also was informed that an immediate Civil Penalty of $500.00 will be issued for retaining a resident who developed a prohibited health condition.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES 2 LLC
FACILITY NUMBER: 198603100
VISIT DATE: 03/12/2024
NARRATIVE
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Under Title 22 Division 6, Chapter 8, following deficiency was cited and recorded on LIC809D.

No other health and safety hazard is noted during this visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2024 02:56 PM - It Cannot Be Edited


Created By: Rosaura Valenzuela On 03/12/2024 at 01:53 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
, 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 A
03/26/2024
Section Cited
CCR
87615(a)

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87615 Prohibited Health Conditions-(a) Persons who require health services for or have a health condition including but not limited to, those specified below shall not be admitted or retained at a residential care for the elderly. (1) Stage 3 and 4 pressure injuries. This requirement was not met as
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The administrator will submit in writing to CCL by 3/13/24, how they will correct the cituation and to ensure that moving forward residents with stage 3 or 4 pressure injuries are not accepted or retained in the facility.
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evidenced by:
Based on interviews and records review, the administrator retained a resident with stage 3 and 4 pressure injuries in the facility. This posses an immediate 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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