Office review·February 12, 2026

On February 12, 2026, Licensing Program Analyst Sandra Urena and Licensing Program Manager KaSandra Lopez met with Satenik Alajanyan for an Office Meeting. During this meeting, a Case Management Deficiencies report was issued in conjunction with a complaint visit (Complaint Control # 29-AS-20260127125601). The purpose of this report is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s meeting the LPA explained the reason for the report. During the course of the investigation, it was discovered that a resident who was admitted to the facility on 01/21/2026, following discharge from a medical center, was admitted without the proper documentation (pre-appraisal) to assess the needs of the resident prior to admission. Furthermore, the administrator did not conduct formal admission process and did not complete the required Community Care Licensing forms to create a resident’s file and did not meet nor communicate with the resident’s responsible party, which poses / posed an immediate health, safety or personal rights risk to persons in care. During the walk through of the facility at approximately 11:05 a.m., the LPA observed that a resident in bedroom # 2 was in bed with full bed rails. The bed rails were raised at the time of the visit. When the LPA asked the administrator to provide the doctor’s orders for the full bed rails, the administrator was unable to provide the documentation and/or doctor’s order for the full bed rails. Continues on LIC 809C...page 2. Page 2. At approximately 11:35 a.m. the LPA observed the following physical plant areas in disrepair. Bedroom #3 closet has a hole inside the closet near the ceiling, which appeared to be in size about 12” X 12” inches wide. The bedroom window was stuck and could not be open for fresh air. The window blind is missing two vertical slats, allowing for the light to shine through. At the time of the observation the resident had a piece of clothing hanging by the top of the blind to keep the light from shining in. Per the resident, the next-door neighbor’s outdoor light shines through at night, and it disturbs the resident’s sleep. Bedroom #2 also has vertical blinds slats missing. The window facing the street is missing the window screen, consequently the residents don’t open the window to not let mosquitoes in. The LPA noticed that fire extinguisher which is located by the doorway of the kitchen and the common area, did not have a receipt with the date of purchase. When the LPA asked the administrator for the receipt, the administrator could not provide one. During the physical plant inspection of the facility’s kitchen, at approximately 12:19 p.m., the LPA observed bananas in the pantry area; the bananas were extremely spoiled. The LPA observed the brown bananas to be inside a plastic bag, with liquid spilling from the plastic bag, when the LPA moved the bags, several small cockroaches scurry away. Furthermore, upon inspection of the refrigerator, the LPA observed a bag which had old, spoiled bread, and boxes of cookie dough with the expiration date of 11/10/2025. Inside the refrigerator, the LPA observed several boxes and bags of insulin pens in the refrigerator that belonged to two (2) residents of the facility. The insulin pens were in between other food items, and accessible to residents in care. During the inspection of the insulin pens, the LPA interviewed the staff (S1) present and asked who administered the insulin to the residents, the staff replied that they did. When the LPA asked if the staff were qualified staff (LVN, RN) to administer the insulin injections, the staff replied, “No, but the administrator said we could”. Continues on LIC 809C... page 3. Page 3. Two (2) people who identified themselves as facility staff were on the premises caring for the residents during the course of the investigation. Upon inspection of the staff files, it was observed by the LPA that the two people caring for the residents did not have background clearance, were not associated with the facility per the department’s personnel summary report and had not received the required training by the CCL department. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Citations were issued. Exit interview conducted, and a copy of this report and appeal rights were provided.