Routine inspection·February 4, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:00 AM. LPA met with facility staff who contacted the facility administrator Nelli Tadevosyan. The Administrator arrived to the facility at 09:17 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:17 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: KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications and a first aid kit. LPA observed a properly secured under-sink cabinet to contain cleaning supplies. One (1) cabinet was observed to contain adequate emergency food and water supplies. The oven was observed to be equipped with child proofing knobs rendering the appliance inoperable while not in use. Continued on LIC 809C. COMMON AREAS : This includes the living room, hallway, and dining area. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. The dining area contained a cabinet and drawers with activities for resident use. LPA observed a fire extinguisher mounted in the dining area to be fully charged and purchased on 01/18/2025. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed a hallway closet to contain extra linens. The facility’s combination fire and carbon monoxide alarms were tested at 10:01 AM and were functional at the time of the visit. BEDROOMS : There are four (4) bedrooms in the facility; three (3) are a dual occupancy resident rooms and one (1) is a staff room. 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. One (1) resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit. 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 118.9 and 120 degrees Fahrenheit, which is in compliance with regulation. LPA observed both bathrooms to contain appropriately secured under-sink cabinets containing cleaning supplies and personal grooming supplies for resident use. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain an appropriately fenced off pool that was inaccessible to residents in care. Continued on LIC 809C. GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, an extra refrigerator, and an extra freezer. The extra refrigerator was observed to contain resident medications that required refrigeration. RECORD REVIEW: Record review began at 10:02 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. Four (4) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. One (1) resident’s admission agreement was observed to be missing signatures. One (1) resident file was observed to be missing a property and valuables sheet, a preadmission appraisal, and a negative Tuberculosis (TB) test. MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for two (2) 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. 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 it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/04/2025. 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 with the facility. No staff interviews were able to be conducted at the time of the visit as one (1) staff member had to leave the facility and the Administrator was the only available representative at the time of the visit. During today’s visit LPA obtained a copy of the facility’s 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.