Routine inspection·May 2, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:27 AM. LPA met with facility staff and contacted the facility Administrator Naira Spry. The Administrator stated that they are unable to come to the facility during today’s inspection, but the Owner/Licensee Representative Tigran Gevorgyan (LIC) would be arriving to conduct the visit. LIC arrived to the facility at approximately 10:00 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:30 AM the LPA, along with facility staff #1 (S1) 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 includes the living room/dining area, hallway, and office area. LPA observed the living room/dining area to be clean and properly furnished at the time of the visit. The living room contains a television, activities for resident use, and a fireplace that is appropriately screened and contains no tools. Additionally, the living room/dining area contained a table and adequate seating for resident use. The hallway was observed to be clean and free from obstructions. The office area was observed to contain a locked storage cabinet that contained facility files. Additionally, the office area contained an unlocked storage dresser that contained the facility’s first aid kit and caregiver’s personal items. LPA observed this dresser to contain unsecured resident medications including prescription inhalers, ointments, and staff supplements. Facility staff secured all medications at the time of the visit. The facility’s combination fire and carbon monoxide alarms were tested at 01:02 PM and were functional at the time of the visit. Continued on 809C. BEDROOMS : There are three (3) bedrooms in the facility; two (2) are dual occupancy resident rooms and one (1) is a single occupancy resident room. LPA and S1 toured all three (3) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contains a direct exit to the outdoors of the facility. 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 fire extinguisher to be purchased on 05/21/2024. The kitchen contained a locked under-sink storage containing cleaning chemicals. LPA observed two unlocked kitchen drawers to contain gardening shears and a large sharp two-pronged fork. Facility staff secured the objects during the inspection. BATHROOMS : There are two (2) bathrooms at the facility. One (1) designated as a private bathroom, and one (1) is designated as a shared/common resident bathroom. All bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The shared resident bathroom contained a locked storage cabinet that contained soaps and other hygiene items. The water temperature was initially measured to be between 127.2 and 128.1 degrees Fahrenheit, which is outside of the range required by regulation. LIC adjusted the temperature on the hot water heater during the visit. LPA tested the water temperature again and measured the temperature to be 107.8 degrees Fahrenheit which is in compliance with regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located at the front of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. The backyard of the facility contained a locked laundry room. The laundry room contained the facility’s washer and dryer along with laundry chemicals. Additionally, LPA observed a locked storage shed and a separate dwelling with its own address that is not associated to the facility. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:20 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 documents and trainings. Five (5) resident files were reviewed. Four (4) resident admission agreements were observed to be incomplete and missing signatures and/or the rates charged for basic services. LPA informed LIC, three (3) residents were self-responsible and completed the admission agreements during the inspection. LIC stated that the remaining admission agreement would be completed no later than 05/16/2025. MEDICATION REVIEW: Medication review began at 11:50 AM. Medications for five (5) of five (5) residents were observed. Four (4) of five (5) resident’s Centrally Stored Medication and Destruction Record Sheets (CSMDR) were observed to contain incorrect and out of date information including: dates filled, prescription numbers, names of medications, and dosage of medications. LPA reviewed five (5) resident’s Medication Administration Records (MAR). All medications were observed to be logged appropriately and the number of pills remaining in medication bottles was consistent with appropriate administration of the medications. LPA informed LIC of the inaccuracies on the CSMDRs and facility staff updated the four (4) identified resident CSMDRs to accurately reflect their prescribed medications during the visit. 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 04/02/2025. 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 three (3) residents. Two (2) of the three (3) residents interviewed stated that the staff treat them well and are attentive to their needs. Two (2) of the three (3) residents interviewed had no concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. Continued on LIC 809C. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current 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.