Golden Years Assistance Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with facility staff and explained the reason for the visit. House Manager Ovsanna Khayalyan arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The facility is a single story family home consisting of a living room, dining room, kitchen, 3 resident bedrooms and 2 full bathrooms. The facility is located behind the home with the address of 15015 Marlin Place. The facility is fire cleared for 5 Non-Ambulatory and 1 Bedridden resident. Bedroom #2 is designated for bedridden use. The following was observed: At approx 09:30 a.m. LPA observed resident watching television in the living room. (1) staff was cleaning while the other staff was attending to the residents. LPA inspected the kitchen/food service area. Knives and sharp objects were observed stored inaccessible in a drawer to the right of the stove. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. LPA observed resident bedrooms, each room was observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit. Laundry area located in staff designated bathroom, inaccessible to residents in care. In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating areas and dining room furniture were observed to be in good condition. LPA observed the required postings throughout common areas. The temperature inside the facility was maintained at a comfortable level throughout today's visit. A working telephone and a laptop is present. There is sufficient space for residents to conduct activities. The outdoor area has covered outdoor seating areas equipped with furniture for residents' use. There were no bodies of water observed. There was one (1) storage shed observed outside, inaccessible to residents in care. LPA observed shed to store cleaning supplies, equipment, various tools / items for facility use. There is also a storage box near the front door. LPA observed it to store emergency water at this time. There is no garage onsite. Records review, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. At approx 12:45 p.m. LPA observed residents finishing lunch. Medications are centrally stored in a cabinet above the microwave. LPA observed it to be inaccessible to residents in care. Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 05/06/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Emergency supplies and records were observed stored in facility emergency disaster box located on shelf by dining room. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit. Smoke detector / carbon monoxide detectors are checked every 3 months by staff. Fire extinguishers were observed to be fully charged and last purchased on 03/2026. During today’s visit LPA conducted interviews, updated facility mobile number and obtained a copy of the facility’s LIC 500, Limited Liability Insurance along with resident roster. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 26, 2026

Allegation investigated: . Staff did not provide assistance to resident as needed 2. Staff did not provide resident's records to emergency personnel in a timely manner 3. Staff did not maintain facility clean

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and was allowed entry into the home by Stella Gevorkova, Staff. Staff contacted Ovsanna Khayalyn, Corporate Officer and she arrived at 11:13am to conduct the visit. The reason for today's visit was provided. On today's visit, LPA Yee conducted interviews with Ovsanna Khayalyn at 1:38pm, Staff #1 at 2:29pm, attempted to interview Resident #1 at 3:19pm and reviewed and obtained copies of facility records throughout the visit. A tour of the facility, inside and outside, was also conduted at 1:08pm. Per information received from interviews conducted regarding the allegation that staff did not provide continued on LIC9099-C Unsubstantiated Page 2. assistance to resident as needed, the investigation revealed that on the morning of May 4, 2026, around 8:00am or 8:15am, Staff #1 had finished changing Resident #1's diaper and had taken the soiled diaper to the outside trash can and returned to the room to prop the resident up in bed, in preparation tor feeding the resident breakfast. Upon entry into the room, Staff #1 observed the resident having a spasm, with mouth open and eyes rolling backwards. Staff #1 immediately called Ovsanna Khayalyn and placed the phone on speaker mode and started chest compressions on Resident #1. Per information provided, Laura Garcia, Licensee, called 911 and Ovsanna Khayalyn jumped in her vehicle and headed to the facility. Ovsanna Khayalyn lives close by and arrived at the facility at the same time as paramedics. Per Staff #1, Resident #1 who was already laying flat on the bed due to the diaper change had difficulty breathing but after administering about 10-15 chest compressions the resident opened their eyes, mouth relaxed back to normal and coughed about 2 to 3 times. Per Staff #1, they did elevate the resident slightly but emergency personnel and Ovsanna had arrived at the facility and they stepped out of the room. Per Staff #1, they observed the paramedics putting a arm cuff on the resident and transferred the resident on to the gurney and taken outside. All this happened very quickly. The paramedics were outside for about 5 minutes while they waited for hospital information. Based on the information obtained, there is insufficient evidence to support the allegation that staff did not provide assistance to resident as needed, therefore the allegation is unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Per information provided by Ovsanna Khayalyn regarding the allegation that staff did not provide resident's records to emergency personnel in a timely manner, she has a separate emergency folder created for each resident. The emergency folder for Resident #1 contains a copy of the Identification and Emergency Contact Information, a copy of the Driver License, a list of medications and the notes from the last medical visit conducted on 3/11/26. Per Ovsanna Khayalyn, she immediately provided the prepared folder to the Continued on LIC9099-C Page 3. paramedics without them having to request it. There was no delay in providing any documents. Based on the information obtained, there is insufficient evidence to support the allegation that Staff did not provide resident's records to emergency personnel in a timely manner, therefore the allegation is unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. A tour of the facility, inside and outside, was conducted to inspect the common areas, all three resident bedrooms, common bathroom and the outside areas at 1:08pm to investigate the allegation that staff did not maintain facility clean. Per tour of the common areas, bedrooms and outside areas, LPA Yee observed that all the areas inspected were clean and well maintained. There were no urine or body fluids or any odors observed on today's visit. Residents were also observed to be clean and doing well. Based on the information obtained, there is insufficient evidence to support the allegation that Staff did not maintain facility clean, therefore the allegation is unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2026 · control 29-AS-20260504151844

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to deficiencies observed during a visit to the facility today. LPA Yee was let into the home by Stella Gevorkoka, Staff. Staff contacted Ovsanna Khayalyn, Corporate Officer and she arrived at 11:13am to conduct the visit. The reason for today's visit was provided. Upon arrival at the facility LPA Yee was looking for the trash can and opened the cabinet located under the kitchen sink. Observed in the cabinet were cleaning solutions such as 409,Comet, Palmolive dish soap, Tide, laundry detergent, Ziploc freezer bags and 3 bottles of Mazola cooking oil, all stored together. LPA Yee observed that the cabinet was left unlocked and staff was away from the kitchen. Yee advised Staff that the cabinet must be kept locked at all times. A tour of the facility was also conducted on today's visit and LPA Yee observed that Resident #1 and Resident #6's beds were equipped with full bed rails and they are not on hospice. Written physician's orders also do not specify the need for full bed rails. Resident #5's bed is equipped with a half bed rail and there is no written physician's order on file for the use of the half rail. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, Appeals Rights discussed and a copy was provided.the state’s words, verbatim · CDSS document, May 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(1) · Plan of correction due date: May 15, 2026

Storage Space and Access Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,.... and other similar items which could pose a danger to residents are in which could pose a danger to residents are in locked storage and are not ...1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. Cooking oils were stored together with cleaning solutions/Detergentsthe state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: Licensee will ensure that Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. Licensee will review the items stored in the cabinet under the kitchen sink and any other areas that is used for storage of cleaning solutions and laundry detergent and relocate any food that is stored together with the cleaning solutions, laundry detergent and any poisons. Submit evidence that the deficiency has been corrected by 5/15/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)B) · Plan of correction due date: May 21, 2026

Postural Supports. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. Based on observation and record review, Resident #1 and Resident #6 were observed using full bed rails and both are not on hospice. The doctor's orders also do not specify the use of full bed railsthe state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: Licensee will either remove the full bedrails for Resident #1 and Resident #6 and replace with 1/2 bed rails or submit a written request for the use of full bed rails and all suppporting documents for the use of full bed rails for consideration by 5/21/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: May 21, 2026

Postural Supports: Based on the individual's preadmission appraisal, and subsequent changes to that appraisal.....Postural supports may be used under the following conditions. A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record he licensing agency shall be authorized to require other additional documentation if needed to verify the order. Per record review and observation, Resident #5 had 1/2 bedrails mounted on the bed and did not have any written order from a physicianthe state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: Licensee will ensure that residents who have a need postural supports, obtain a written physiican's order prior to its use and maintain in the resident's file. Licensee will remove the 1/2 bedrail or obtain a written physician's order prior to use. *****THE 1/2 BED RAIL WAS REMOVED RESIDENT #5' BED DURING THE VISIT*****

Type of visit: Prelicensing

Licensing Program Analyst Christine Yee conducted an announced Prelicensing and Component III visit using the complete CARE Inspection Tool. LPA Yee met with Laura Aceituno Garcia, Applicant/Licensee and Ovsanna Khayalyn, Corporate Officer. The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 resident bedrooms and 2 full bathrooms. The facility is located behind the home with the address of 15015 Marlin Place. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #2 is designated for bedridden use. The following was observed on today's visit: the living room and dining room is furnished with the appropriate furniture and sitting. Located in the living room is a desk, a filing cabinet for staff and resident files and the facility telephone. The facility phone number is (747)264-1052. the kitchen is equipped with a refrigerator, stove, microwave and coffee maker. Located in the kitchen is the only fire extinguisher purchased on 2/11/25. Dish washing detergent and cleaning solutions are stored in a locked cabinet under the sink. Knives are stored in a locked kitchen drawer and medications will be stored in a locked kitchen cabinet. Sufficient non-perishables foods were observed for a minimum of 7 days but could be supplement with more protein foods. Perishables foods for a minimum of 2 days will be purchased prior to accepting the first resident. All 3 bedrooms are furnished with 2 twin beds, 2 night stands, 2 lamps, 2 covered trash cans, 1 chair and a built in closet. sufficient bed linens and towels were observed in the closet of the 3 bedrooms except for blankets. A total of 5 blankets were observed. Additional blankets need to be purchased to allow for changing. the common bathroom located by bedroom #3 is equipped with a walk in shower, a toilet and a single sink. A slip resistant mat and grab bars were observed in the walk in shower and by the toilet. The water temperature was tested and read 123.3 degrees Fahrenheit. The staff bathroom located closest to the living room is equipped with a bath tub and a shower, a toilet and a sink. A slip resistant mat and no grab bars were not observed in the shower or by the toilet. Water temperature was tested and read 122.7 degrees Fahrenheit. Located inside the bathroom is the washer and dryer. Additional hygiene products, cleaning solutions, laundry detergent were observed stored in a cabinet under the sink and in a mounted cabinet. Recommendation was made to lock the cabinets to ensure that the items would be inaccessible to the residents if staff forgot to lock the bathroom door or if the bathroom was needed in an emergency. The hard wired smoke detectors located in the 3 bedrooms and the only combination smoke/carbon monoxide detector located in the hallway were tested and were operational. A first aid kit with the required tweezer, scissors, thermometer and supplies was observed. A first aid manual was also observed. the outside area was observed with a covered gazebo with a padded bench, a table with 4 chairs, a rattan bench and a chair with a glass table. Trash cans were observed to be tightly sealed. The outside areas were observed to be clean and well maintained. The following deficiencies need to be corrected prior to licensure: the thermostat for the water heater needs to be adjusted and the water temperature in the two bathrooms needs to be within a range of 105-120 degrees Fahrenheit. 3 additional chairs need to be provided in the 3 bedrooms 7 twin blankets need to be purchased to allow for changing Grab bars need to be installed in the staff bathroom for emergency resident use. locks need to be placed on the cabinets that contain the cleaning supplies, laundry detergent and hygiene products in the staff bathroom to allow for emergency resident use. provide a dedicated internet device for resident use with a device usage policy purchase additional non-perishable foods and proteins to supplement the food currently in the facility. The following will be completed upon licensure of the facility: purchase liability insurance with limits of a $1 million dollars per occurrence and $3 million total aggregate. purchase perishable foods for a minimum of 2 days prior to accepting the first resident and to be maintained on the premises. Files will be created for all residents, staff and any volunteers Component III was also conducted with Laura Aceituno Garcia, Applicant and Ovsanna Khayalyn, Corporate Officer on today's visit. Applicant will notify LPA Yee once all the corrections have been completed and evidence of corrections are provided. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2025