Routine inspection·July 9, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:16 AM. LPA met with staff #1 (S1) who contacted the facility Administrator Emma Avetisyan. The Administrator arrived to the facility at 12:25 PM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:20 AM the LPA, along with 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: 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 the dry food storage cabinet to contain one jar of opened and expired hot pepper sauce. LPA informed the Administrator who discarded the jar during the visit and agreed to conduct an audit of the facility’s food supplies. LPA observed a secured cabinet to contain resident medications, knives, and other sharp objects. LPA observed the kitchen to contain the facility’s washer and dryer. LPA observed a camera in the kitchen that appeared disabled with the lens covered. Continued on LIC 809C. COMMON AREAS : This includes the living room and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television and activities for resident use. LPA observed the living room to contain an cabinet located under the television. LPA observed a secured section of this cabinet to contain resident and facility files. LPA observed an unsecured drawer in this cabinet to contain Monday-Sunday pill organizers filled with medications accessible to clients in care. LPA informed the Administrator who secured the medications at the time of the visit. The dining area was observed to be equipped with adequate seating for resident use. LPA observed a fire extinguisher mounted on the wall of the dining room to be purchased on 06/26/2025. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:11 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS : There are four (4) bedrooms in the facility; two (2) are dual occupancy resident rooms, one (1) is a single occupancy resident room, and one (1) is a staff room. LPA toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contained a direct exit to the outdoors of the facility. BATHROOMS : There is one (1) bathroom at the facility. It is designated as a shared/common resident bathroom. The resident bathroom was observed to be clean and was equipped with nonskid surfaces. Grab bars were observed in the resident shower and near the resident toilet. The water temperature was measured to be 113.5 degrees Fahrenheit, which is within the range required by regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed an unlocked storage shed that contained tools, saw blades, paints, and pesticides. LPA informed the Administrator who secured the shed during the visit. Continued on LIC 809C. RECORD REVIEW: Record review began at 11:25 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. One (1) staff member, staff #2 (S2) was observed to have fingerprint clearance but was not associated to the facility. LPA informed the Administrator that employees must obtain a fingerprint clearance and be associated to the facility prior to working, residing or volunteering in a licensed facility. LPA informed the Administrator that a civil penalty in the amount of 500$ (1 Employee x 100$/day x 5 days [maximum of 5 days] = $500) will be assessed on today’s date (07/09/2025) for not having submitted a criminal record clearance transfer request for S2. All other staff files contained all required documents and trainings. Five (5) resident files were reviewed. Resident #1 (R1)’s medical assessment was observed to contain inaccurate information after a change in condition. LPA did not observe a reappraisal in R1’s file. LPA informed the Administrator who agreed to obtain an updated medical assessment for R1 which accurately reflects R1’s current condition. Resident #2 (R2)’s medical assessment was observed to be dated 11/03/2023 and R2 was admitted to the facility on 01/27/2025. LPA informed the Administrator that prior to a person's acceptance as a resident, they shall obtain documentation of a medical assessment made within the last year. The Administrator expressed understanding and agreed to obtain an updated medical assessment for R2. All other resident files contained all required documentation and signatures. MEDICATION REVIEW: Medication review began at 12:25 PM. Medications for two (2) of five (5) residents were observed. Resident #3 (R3)’s medications were observed to have the incorrect prescription numbers documented on their centrally stored medication and destruction record sheet (CSMDR). LPA informed the Administrator who agreed to conduct an audit of the resident’s CSMDR’s to ensure accurate information. 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 04/18/2025. 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. Continued on LIC 809C. INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. LPA interviewed one (1) staff member, S1. 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. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. The Administrator had to leave the facility at the time of the inspection but has designated staff #2 (S2) to sign this report on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.