Follow-up·July 17, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a post-licensing continuation visit at 9:40AM. The LPA met with the Licensee Naira Nikoyan and explained the reason for the visit. Entrance interview conducted. At 10:10AM, the LPA and the Licensee briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At this time, no immediate health and safety hazards were observed. During the initial visit on 07/11/2025, the LPA observed the following: PHYSICAL PLANT: In the food pantry located in the hallway, the LPA observed expired non-perishable foods dated from 10/27/2022 to 05/28/2025. The Licensee was unaware of the expired food and stated they would update the pantry. Resident #1 (R1) resided in the second living room and was observed to have oxygen administered. Residents in Bedroom #3 also had oxygen stored in their room for use as needed. The LPA did not observe signage stating oxygen was in use for these areas, but did observe one signage for Bedroom #1. The Licensee stated that R1 was not receiving oxygen, and the LPA pointed out the operating oxygen machine attached to the foot of R1’s hospital bed. The Licensee stated Resident #2 (R2) and Resident #3 (R3) were not currently receiving oxygen but utilize it sometimes. Report Continued on LIC 809-C The LPA informed the Licensee that signage of “oxygen in use” need to be posted for safety reasons. In Bedroom #1’s private restroom, the LPA did not observe grab bars along the toilet nor the shower. Additionally, the sink in the restroom was clogged and slow to drain. The Licensee stated that the Hospice nurses utilized the sink to discard water used for the residents’ showers and advised them not to do so. MEDICATIONS: Medications were reviewed for R2 and R3. For R2, three (3) PRN (as needed) medications were observed (Senna-Time 8.6MG, Melatonin 5 MG, and Hydrocodone-Acetamin 5-325MG) and did not have PRN Authorization Letter on file. Several of R2’s prescribed medications were not recorded on a Centrally Stored Medication and Destruction Record (CSMDR) which included Potassium CL ER 10 MEQ filled on 07/02/2025, One Daily Vitamin, Metformin HCL 500MG, Fenofibrate 54MG, and Atorvastatin 10MG each filled on 07/06/2025. Metformin HCL 500MG prescribed on 06/09/2025 was instructed for R2 to take 4 tablets daily, and one dose of 4 tablets remained. R2’s Furosemide 40MG, filled and started on 07/02/2025, was prescribed at 1 tablet twice daily but had not been administered. Cranberry 450MG also filled and started on 07/02/2025 had 6 tablets prepped by Staff and 8 tablets were administered; however, 10 total tablets should have been administered, indicating a discrepancy. R3 had three (3) PRN medications (Hydralazine 25MG, Hydrocodone-Acetamin 5-325MG, and Lorazepam 0.5MG) but did not have a PRN Authorization Letter, nor were any administration logs recorded. Medications filled on 07/06/2025 including Losartan Potassium 25Mg, Glipizide 5MG, and Gabapentin 300MG were scheduled to begin 07/01/2025, were not administered. Melatonin 10MG, filled and started on 07/08/2025, had also not been administered as prescribed. R3’s Nortriptyline HCL 25MG, filled on 07/06/2025 and started 07/01/2025 had 7 tablets prepared by Staff and only 5 tablets taken by R3. Both trazodone 100MG and Atorvastatin 40MG had 7 tablets prepared by Staff, and the remaining tablet counts did not align with the expected usage. Glipizide 5MG filled and started on 06/07/2025 was prescribed at 1 tablet twice daily; it was observed that 19 tablets had been taken from the Morning pack and 10 tablets taken from the Evening pack. The total usage and prescription instructions suggested the medication should have been completed. Report Continued on LIC 809-C Gabapentin 300MG, also filled on 06/07/2025 and taken three times daily, was noted to have 7 capsules left in the Morning pack, 8 in the Evening pack, and the Bedtime pack was unaccounted for. R3’s Furosemide 20MG, filled and started on 06/23/2025, was prescribed for daily intake unless blood pressure dropped below 110 or heart rate below 60. 8 tablets remained, and there was no documentation indicating the medication had been held. Two (2) packs of Jardiane 25MG were observed for R3, both prescribed for daily use. The first pack contained 25 tablets, while the second contained 9 tablets. These packs were filled two (2) days apart, with labels observed to be altered. The Jardiane 25MG was not properly recorded on the CSMDR. The Licensee stated that the residents did not need to take certain medications because they were already taking medications that addressed those same issues. The Licensee did not follow the medication prescription labels and stated that the residents did not want to take the medications, and the Licensee stopped offering them. The Licensee did not order the residents’ medications, but the Hospice Agency was responsible for it, and the Licensee was following the Hospice Nurses’ instructions. The LPA informed the Licensee that they need to follow the Physician’s orders and administer medications according to the medication labels. If the Licensee observed a change in the resident, the Licensee would need to contact the prescribing Physician to make adjustments. The LPA also informed the Licensee that there needs to be documentation of resident refusals, and the Licensee would need to continue offering the medications and inform the prescribing Physician. Additionally, PRN medications need to be documented each time they are administered which include the reason for the administration, date, and time. The CSMDR also showed inconsistencies pertaining to the date filled and date started of each medication. The LPA also discussed with the Licensee reporting requirements, as R3 was observed to be admitted to the hospital. Report Continued on LIC 809-C RECORDS: Record review of resident files revealed that R2, R3, and Resident #4 (R4) did not have completed documents such as Admission Agreements, Appraisals, Personal Rights, and Consent Forms. R2 and R3 had Physician’s Reports, however, R4 did not have their Physician’s Report or TB test results. R1 was admitted to the facility on 07/09/2025 and the Licensee did not complete any required documents upon admission to the facility. The Licensee stated they were waiting for R1’s family and Hospice to provide the documents. The LPA informed the Licensee that the required documents should be completed prior to being admitted to the facility. The Licensee stated they would work on obtaining and completing the required documents for all residents. The LPA was not able to complete a review of Personnel records because the Licensee did not have any documentation completed for two (2) Staff in addition to both Staff not being fingerprint cleared. Staff #1 (S1) had been employed since 02/25/2025 and assisted residents as well as maintained facility files. Staff #2 (S2) had been employed since 07/02/2025 and had since been the primary caregiver in addition to the Licensee. S1 and S2 did not obtain their First Aid/CPR training or receive their 40 hours of initial training. S1 and S2 need to complete their Personnel Records, Health Screening with TB test results, First Aid/CPR Training, Criminal Record Statement and Clearance, and 40 hours of initial training. The facility has not conducted any emergency drills or maintained their Infection Control Plan and Emergency Disaster Plan. The LPA requested the documents and the Licensee and S1 were unable to provide them. Additionally, files were not readily available nor kept and maintained in a centrally stored location on the facility’s premises. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies are cited (Refer to LIC 809-D). Exit interview conducted. A copy of today’s report and appeal rights were reviewed and provided.