Routine inspection·March 27, 2025

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Naira Aghajanyan, Staff. Rebeka Durgaryan, Administrator was contacted by staff and LPA Yee was advised that Laura Hovhannisyan, Designated Responsible Staff would conduct today's visit since she was on vacation. A completed LIC308 - Designation of Facility Responsibility was observed in the staff's file. Ms. Hovhannisyan arrived a little later to conduct the visit. The reason for today's visit was provided. The home is a single storey family home consisting of 5 bedrooms, 3 full bathrooms of which one is designated for staff use, a living room, dining room, a den, office and a kitchen. All five bedrooms are now used by residents. The facility is fire cleared for 1 BEDRIDDEN and 5 NON-AMBULATORY residents. Bedroom #2, located in the back right hand corner, is designated for Bedridden use On today's visit, LPA Yee reviewed 6 resident files, 7 staff files, and completed the following 2 domains of the CARE Inspection Tool 1. Infection Control and Personnel Records/Staff Training. A quick tour of the 5 residents rooms was conducted to verify the use of each room due to changes observed from previous visits conducted to the facility. Bedroom #5, by the front door was formerly designated for Staff use was observed with 1 resident and Bedroom #4, directly by the dining room was formerly used for storage was observed with 1 resident in a hospital bed with full bed rails. Bedroom #3 has 2 beds with 2 residents, Bedroom #2 was observed with 2 beds and Bedroom #1 was observed with 2 beds and 1 resident. A total of 8 beds were observed and the facility is licensed for a capacity of 6. The facility may only have beds for the capacity CONTINUED ON LIC809-D for which it is approved. The Licensee needs to do the following: Per file review, the facility does not have physicians orders on file for all centrally stored medications and needs to contact the prescribing physician to obtain copies of the Physician orders. the facility needs to remove all full bed rails and half bed rails that are being utilized by residents that are on hospice but it is not included in their hospice care plan and half bed rails if there is no doctor's order for the use of the rails and provide evidence to the Department of removal. the facility is providing quarterly simulated class room drills with all staff present during the morning shift but are not conducting unannounced simulated fire drills during different shifts. the facility needs to update the facility sketch to include room numbers, location of shutoff valves and the meeting point in an emergency. Resident #1 does not have a primary diagnosis noted on the Physician's report Resident #4's Physician Report does not indicate if the resident is able to leave the facility unassisted. The facility electrician was at the facility today to repair a smoke detector. During this visit, the hard wired smoke detectors in the all residents rooms, living room and the combination smoke/carbon monoxide detector located in the office and outside bedroom #3 were tested and were all operational. Due to time constraints and issues with obtaining records a return visit is needed to complete the annual inspection. Any deficiencies not cited on today's visit will be cited on a return visit. Exit interview was conducted.