Pre-licensing visit·October 9, 2025

Licensing Program Analyst (LPA) Trevor Byrne conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Sargis Ayvazyan. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is a one story home. At 10:14 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for two (2) non-ambulatory residents and four (4) of bedridden residents. The facility has five (5) private resident bedrooms, Rooms # 1, 2, 5, and 6 and one (1) shared room, Room # 5. All resident rooms have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which included, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. Room # 3 is a designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) bathrooms in the hallway. One (1) is designated as a staff bathroom. The resident bathrooms had a shower with non-skid materials. The toilets and showers had grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F. Continued on LIC 809C. Resident and staff records are stored in a filing cabinet, which is currently located in the Administrator office. Medications are centrally stored in a locked cabinet in the living room. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a wall mounted box in the kitchen. Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents via child proofing covers . The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of non-perishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet under the kitchen sink and in the garage. No flies or other vermin were observed. LPA observed the living room to be missing furniture for resident use. There are televisions and other entertainment equipment in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight were made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. Alarms on all but the office exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had sufficient emergency lighting. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There was one (1) fire extinguisher throughout the house. It was fully charged and did not exceed the expiration date. Continued on LIC 809C. Hot water was tested in each bathroom, which included the resident bathrooms and any common bathrooms, in addition to the kitchen; and, the hot water ranged from 114.3 to 118.9 degrees Fahrenheit. The laundry area is located in the garage of the facility. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a locked cabinet in the living room. Extra incontinence supplies are stored in the garage There is a functioning telephone on the premises. The emergency telephone numbers are posted in the entryway of the facility along with the other required postings. The exterior passageways were clean and clear of any obstructions. LPA observed seating in the backyard that lacked appropriate shading. The entire property is not fenced but construction is ongoing. The back and sides of the house are separated from the front yard by gates. There is a locked storage shed in the back yard. There are not any bodies of water on the premises at the present time. The garage is accessible from the house. COMP III orientation was completed with the applicant during this pre-licensing inspection. The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Byrne so that your application may be completed. This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. 87219 Planned Activities (h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (1) A comfortable, appropriately furnished area such as a living room, available to all residents for their relaxation and for entertaining friends and relatives. Continued on LIC 809C. 87219 Planned Activities (h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. 87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.