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Inspection visit

Routine inspection

MARY ELLEN HOMESLicense 1958500892 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:29 AM. LPA met with Administrator Gohar Khachatryan. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:30 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS : This included the living room, hallway, and dining area. The living room was observed to be clean and in good repair and contained adequate seating for resident use. The living room contained an adequately screened fireplace and activities for resident use. LPA observed a fire extinguisher mounted in the living room to be fully charged and purchased on 01/26/2026. LPA observed a properly secured medication cart which contained resident medications and a mini refrigerator for medications requiring refrigeration. LPA observed one (1) unlocked hallway closet which contained extra linens and one (1) additional locked hallway closet which contained the facility’s washer and dryer along with cleaning and laundry chemicals. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contained a dining table with adequate seating for resident use. The facility’s combination fire and carbon monoxide alarms along with the facility’s fire door were tested at 09:51 AM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. Cont on LIC 809C. BEDROOMS : There are four (4) bedrooms in the facility; two (2) are a dual occupancy resident rooms and two (2) are single occupancy resident rooms. LPA and facility administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #4 is the bedridden approved room and contained a direct exit to the backyard of the facility. LPA observed bedroom #1 to contain an unsecured box of prescription medications. LPA notified the Administrator who secured the medications. BATHROOMS : There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 108.3 and 112.3 degrees Fahrenheit, which is in compliance with regulation. OUTDOOR SPACE: The facility has an emergency exit gate located in the front yard; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain an extra refrigerator and two (2) storage sheds. One (1) shed contained care supplies and one (1) locked shed contained gardening supplies and cleaning chemicals. RECORD REVIEW: Record review began at 10:00 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documentation and trainings. Five (5) resident files were reviewed. Four (4) resident files were observed to contain out of date Appraisal Needs and Services plans (ANS). LPA notified the Administrator that reappraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition. The Administrator expressed understanding and completed updated ANS for the identified residents during the visit. MEDICATION REVIEW: Medication review began at 11:10 AM. Medications for three (3) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Cont. on LIC 809C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: 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 they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/26/2026. 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. INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns or recommendations for improvement for the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s updated emergency disaster plan, LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

Citations

2 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87463(a)Type B

    Based on record review, the licensee did not comply with the section cited above as four residents files contained appraisal needs and service plans that were not updated within the last 12 months which poses a potential health, safety or personal rights risk to persons in care.

  • 87465(h)(2)Type A

    Based on observation, the licensee did not comply with the section cited above as bedroom #1 to contained an unsecured box of prescription medications which posed an immediate health or safety risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the February 18, 2026 inspection of MARY ELLEN HOMES?

This was a inspection inspection of MARY ELLEN HOMES on February 18, 2026. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to MARY ELLEN HOMES on February 18, 2026?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "Based on record review, the licensee did not comply with the section cited above as four residents files contained appra..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

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