Follow-up on corrections·February 25, 2026

Licensing Program Analyst (LPA) Trevor Byrne conducted a case management - deficiencies visit at the facility today. LPA arrived to the facility at 10:15 AM. LPA met with facility staff who contacted the Administrator Lousine Sarkisian via telephone call. The Administrator arrived to the facility at 10:27 AM. Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a brief physical plant tour, collected copies of documentation, and conducted interviews with two (2) residents, the Administrator, and one (1) staff between approximately 10:28 AM and 04:30 PM. During the physical plant tour LPA observed a shed located on the side of the house. The shed was observed be unlocked with a key placed into the lock left unattended. LPA observed this shed to contain various cleaning chemicals. LPA informed the Administrator that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. The Administrator expressed understanding and secured the chemicals at the time of the visit. LPA observed bedroom #3’s direct emergency exit to be blocked by a chair. Additionally LPA observed the facility’s front door to contain a deadbolt with a key lock on both sides of the door. LPA observed this deadbolt to be locked at the time of the inspection. LPA informed the Administrator that the facility does not have the appropriate fire clearance to lock doors leading to the exterior of the facility nor did the facility notify Community Care Licensing Division of their intent to lock exterior doors. LPA informed the Administrator that this constitutes a violation of the facility’s fire clearance and that this is a zero tolerance violation. LPA informed the Administrator that an immediate civil penalty in the amount of $500 is being assessed on today’s date (02/25/2026) for a violation of the facility’s fire clearance. Continued on LIC 809C. The Administrator expressed understanding, removed the chair from bedroom #3’s exit door, and installed a standard deadbolt on the facility’s front door at the time of the visit. During the physical plant tour LPA observed Staff #1 (S1) working at the facility providing care and supervision to the residents. LPA was informed by the Administrator that S1 had worked for the facility since 07/02/2025. LPA reviewed the list of individuals associated to the facility and did not observe S1 associated to the facility. LPA informed the Administrator that all individuals subject to a criminal record review shall obtain a criminal record clearance and be associated to the facility prior to working, residing or volunteering in a licensed facility. LPA informed the Administrator that not having S1 associated to the facility would result in the assessment of a Background Check Civil Penalty (BCCP) in the amount of $100/day per employee for a maximum of five (5) days for the first offense. LPA stated that a civil penalty in the amount of $500 is being assessed on today’s date (02/25/2026) for S1 not being associated to the facility. The Administrator expressed understanding and agreed to associate S1 to the facility. During record review LPA observed an incident that occurred with Resident #1 (R1) on 02/20/2026. LPA interviewed the Administrator who stated that R1 arrived to the facility on 02/18/2026 and was discharged back to the hospital on 02/20/2026. The Administrator informed LPA that no preadmission appraisal of R1 was conducted and no physician’s report for R1 was obtained prior to R1 entering the facility. LPA informed the Administrator that prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs. Additionally, LPA stated that prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year. The Administrator expressed understanding and confirmed that they were aware of these requirements. The Administrator stated that R1 would not be returning to the facility but agreed to submit a statement of understanding confirming that they are aware of, and will complete, all required pre-admission documentation prior to accepting residents into the facility. Pursuant to Title 22 California Code of Regulations the following deficiencies were cited and civil penalties were assessed. Exit interview conducted, report was reviewed, and a copy of the report and appeal rights were provided.