Routine inspection·August 12, 2024

On 8/12/24 Licensing Program Analysts (LPA) K. Kaur and J. Leffall arrived unannounced to conduct an Annual Inspection. LPAs introduced themselves, stated the purpose of the visit, and were allowed entry by staff Kelly Gordon. Staff contacted Administrator Hripsime Makaryan who arrived a short while later. 4 clients were present during inspection. LPAs toured facility with staff. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. During living room tour, LPA’s observed fireplace without a screen. Cleaning chemicals was observed stored and locked closet next to entry door. Fire extinguisher was observed with a service date of: 6/7/24. Fire drill last completed on 5/23/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Inside bathroom toured and observed to be operational. LPAs observed grab bars next to toilet and in shower. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seating and shaded area under patio. LPA’s observed a portable built bathroom next to patio in backyard at 12:18 PM. Toilet observed without grab bars. During medication and MARS review, LPAs observed Centrally Stored Medication and Destruction Record (CSMDR) was incomplete. Medications were checked and observed kept locked in closet in the kitchen. Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ files reviewed to have all the required documents. Staff files were reviewed and observed to have all the required documents. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Deficiencies are as follows: Outside Portable built bathroom without obtaining building permit, fireplace without screen, Centrally Stored Medication and Destruction Record incomplete, and missing grab bars in portable bathroom. Continued to 809C LPA is requesting the following documents be submitted to the Fresno CCL office by 8/19/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided.