Post-licensing visit·May 1, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a post-licensing visit at 10:07 AM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 10:52 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:10 AM the LPA, along with 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: 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 lock box to contain knives and other sharp objects. LPA observed a fire extinguisher mounted on the wall to be purchased on 11/06/2024. The kitchen contained a locked under-sink cabinet that soaps and cleaning chemicals as well as a locked cabinet that contained medications. Continued on LIC 809C. COMMON AREAS : This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains activities for resident use and a fireplace, it is appropriately screened and contains no tools. The hallway was observed to contain a storage closet which contained extra care supplies. The dining area was observed to be equipped with adequate seating for resident use. 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 01:42 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 single occupancy resident rooms and two (2) are dual occupancy resident rooms. LPA and S1 toured all four (4) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #1 and #2 contain direct exits to the outdoors of the facility. BATHROOMS : There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom, and one (1) is designated as a shared/common resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed near resident toilets and were properly secured. The water temperature was measured to be between 113.5 and 116.6 degrees Fahrenheit, which is in compliance with regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. RECORD REVIEW: Record review began at 10:57 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. Two (2) staff files were reviewed. All staff files contained all required documents and trainings. Two (2) current resident files and three (3) former resident files were reviewed. The two (2) current resident files contained all required documentation and signatures. No deficiencies were observed during file review. Continued on LIC 809C. MEDICATION REVIEW: Medication review began at 12:50 PM. Medications for two (2) of two (2) 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 04/15/2025. 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 one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident had no concerns with the facility. LPA interviewed one (1) staff member and the facility’s Administrator. The staff member was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During the interview S1 informed LPA that the facility recently had three (3) residents pass away in April. LPA reviewed the facility E-file and did not observe death reports submitted for the three residents. LPA reviewed the deceased residents’ files and observed the dates they passed away to be 04/18/2025, 04/23/2025, and 04/24/2025. LPA interviewed the Administrator and asked why no death reports were submitted to Community Care Licensing Division (CCLD). The Administrator stated that they had attempted to fax the documents multiple times. LPA informed the Administrator that during the visit between 11:14 AM and 11:51 AM they received the three faxed death reports. The Administrator was unable to provide LPA with proof of the death reports being faxed prior to today's insection (05/01/2025). LPA informed the Administrator that all incident and death reports must be submitted to CCLD no later than seven (7) days following the event. 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 during the visit but has designated S1 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 deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.