Follow-up on corrections·June 6, 2025

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management deficiencies visit at the facility at 10:01 AM. LPA met with facility Administrator Aram Muradyan entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, reviewed two (2) resident files, and conducted interviews with the Administrator, one (1) witness, and three (3) residents between 10:05 AM and 12:25 PM. During the physical plant tour LPA observed resident #1’s (R1) bed to contain full-length bed rails. During the interview with R1 they reported that the full bed rails made them feel trapped as they were not able to leave the bed without asking for assistance from staff. LPA reviewed R1’s resident file. LPA did not observe R1 to be on hospice or R1’s file to contain a physician’s order for full bed rails. LPA interviewed the Administrator. The Administrator informed LPA that R1 was not on hospice and did not have an order for full bed rails. The Administrator stated that the bed rails were installed at the request of R1’s family as R1 is considered a fall risk. LPA informed the Administrator that full bed rails may only be utilized by residents who are receiving hospice care and have a hospice care plan that specifies the needs for full bed rails. LPA and the facility Administrator called the family member of R1, Witness #1 (W1) and explained this requirement. W1 confirmed that the rails were installed at their request. The Administrator agreed to remove the full bed rails at the time if the visit. The full bed tails were replaced with half bed rails located on the head half of the bed. Additionally, the Administrator stated that they would install a call button for R1 to utilize to notify staff if they require assistance getting out of bed. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.