Follow-up on corrections·April 30, 2025

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management - deficiencies visit at the facility at 09:56 AM. LPA met with facility Administrator Lilit Tonoyan. The reason for the visit was explained and entrance interview was conducted. During today’s visit LPA conducted a physical plant tour, reviewed five (5) employee files, obtained copies of pertinent documentation, and interviewed the Administrator, two (2) staff, one (1) witness, and two (2) residents between 10:06 AM and 12:50 PM. LPA Byrne interviewed staff #1 (S1) who stated that today (04/30/2025) was their first day working at the facility. S1 stated that they have been living at the facility for “a couple of days”. S1 confirmed that they were not working with the residents prior to today (04/30/2025). LPA interviewed the facility Administrator who confirmed that today (04/30/2025) is S1’s first day working at the facility. The Administrator stated that S1 has been living at the facility since Monday (04/28/2025). LPA reviewed the list of employees associated and cleared to work at the facility. LPA did not observe S1’s name on the list. LPA asked the Administrator why S1 was not associated to the facility. The Administrator informed LPA that S1 had worked for licensed facilities previously and is background cleared. LPA informed the Administrator that a transfer of S1’s criminal record clearance and an association to the facility must be completed prior to S1 working or residing at the facility. LPA informed the Administrator that failure to request a transfer of the criminal record clearance for S1 will result in an immediate civil penalty of $100 per day for a total of $300. This total was calculated as $100/day * 3 days * 1 employee = $300 total and began from the date S1 began residing at the facility until the date of today’s inspection (04/28/2025-04/30/2025). The Administrator stated that they would request a criminal record transfer for S1 to be associated to the facility. Continued on LIC 809C. The following deficiency was cited, and a civil penalty was assessed (Refer to LIC 809D). Exit interview conducted, a copy of the report, civil penalty, and appeal rights were provided.