Routine inspection·January 23, 2025

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Avetis Keshishyan, Staff at 10:27am. Julietta Mirzoyan, Administrator was contacted by telephone and she arrived at 10:58am to conduct the visit. The reason for today's visit was provided. The facility is a single storey family home consisting of a living room, dining room, a kitchen, four resident bedrooms, 2 full bathrooms and a detached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #4 is designated for 1 bedridden resident use. The facility is also approved for 5 hospice waivers. On today's visit, all 12 domains of the Care Inspection Tool was reviewed. The following was observed for the physical plant: The living room was furnished with the appropriate furniture and seating for 6 residents. The fire place was sealed off with a cover. Above the fire place was a mounted television. The outside exiting door is equipped with a auditory device and leads out to a ramp. The front door is equipped with an auditory device that was operational. The dining room was furnished with a table and 6 chairs, The kitchen was observed with a stove with an oven, microwave, toaster oven, toaster and a refrigerator. A cabinet containing resident and staff files was observed. Cleaning solutions and dish soaps were stored in a locked cabinet under the sink. Knives were stored in a locked drawer. The only fire extinguisher purchased on 11/30/24 was observed in the kitchen. Bedroom #1 was furnished with 2 hospital beds, 2 night stands, 2 chairs, 2 lamps, a shared dresser and a built in closet. Window dressings was observed. The beds were not made up as it was vacant. Page 2 The common bathroom was equipped with a shower, a single sink and a toilet. Grab bars and a slip resistant mat and shower chair was observed. Located inside is a locked linen closet with extra blankets, bed linens, bath towels and blankets were observed. Also located in the closet are the hygiene products. Bedroom #2 was observed with a hospital bed with half a bed rail, a night stand, a lamp, a chair, a dresser and a built in closet was observed. Bed linens and blankets per the resident's personal preference was observed. Also observed in the room was an oxygen tank and a oxygen concentrator. Oxygen in use sign was observed on the room door and front door. The required posters were observed by the front door and the labor poster in the kitchen. Bedroom #3 was observed with a hospital bed, a night stand, a lamp, a dresser and a built in closet. The outside exiting door was equipped with a auditory device and leads out to a ramp. Bedroom #4 was observed with 2 hospital beds, 2 night stands, 2 lamps, 2 chairs, a shared dresser, 2 portable closets, and a fire place that has been sealed off. The outside exiting door was equipped with an auditory device and leads out to a ramp. The first aid kit with the required dressings, bandages, tweezer, scissors and thermometer were observed. A first aid manual was also observed. The facility has current liability insurance that meets Title 22 requirements - 1 million per occurrence for a total annual aggregate of 3 million dollars. The facility is completely enclosed on the outside and has a covered patio. A table and 6 chairs were observed for outside activities. The trash cans were observed to be in good condition and were tightly sealed. Overall, the backyard and the front yard was well maintained. No deficiencies were cited on today's visit. Exit interview was conducted and a copy of the report was provided.