Routine inspection·April 7, 2026

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:36AM. LPA met with staff and Administrator Iren Stepanyan who arrived at 11:07AM. Reason for the visit was explained. Entrance interview conducted. Beginning at 11:05AM, LPA, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards. The following was observed: KITCHEN/LAUNDRY: LPA observed the kitchen area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA observed a fire extinguisher which was fully charged but with an unknown date of purchase. Staff purchased and installed a new fire extinguisher during the visit. Washer, dryer, and laundry supplies were observed by the kitchen and kept inaccessible to residents. BEDROOMS: There are four (4) bedrooms total of which two (2) are for single resident-use and two (2) are for shared resident-use. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed full bed rails equipped for two (2) residents who are not receiving hospice services. Administrator obtained half-rail orders for the two (2) residents during the visit and stated the full rails will be replaced to half rails. Bedrooms had functioning auditory exit alarms. Continued on LIC-809-C. RESTROOMS: There are two (2) restrooms of which one (1) is attached to Bedroom #2 and one (1) is in the hallway. Restrooms were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. At 11:32AM, LPA measured the hot water in the hallway bathroom to be 139.7 degrees F, which is above the required range of 105-120 F. Staff lowered the water heater and at 12:09PM, LPA re-measured the water to be 136.9 F. Water heater was lowered again and at 03:14PM, LPA measured hot water at 94.8 F. Staff raised the water heater and at 03:52PM, LPA measured the hallway bathroom for a final time to be 93.6 F. Administrator stated they will raise the water heater and monitor the hot water to be within range, and also install a caution sign above the faucet for hot water above 125 F. COMMON AREAS: LPA observed common areas to be clean and properly furnished. LPA observed cameras in common areas and Administrator disabled the audio component during the visit. At 11:40AM, fire alarms/carbon monoxide detectors were tested and functioned properly. All exits have functioning auditory devices which were operational during the visit. LPA observed required postings. OUTDOOR SPACE: LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. Passageways were freed and cleared of obstruction. There is a gated and locked pool which was inaccessible to residents. LPA observed a locked garage containing additional storage and supplies. MEDICATION REVIEW: At 11:47AM, LPA reviewed medications for three (3) residents. Medications are centrally stored in a locked filing cabinet in the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents. No errors observed during medication review. RECORD REVIEWS : Beginning at 01:32PM, LPA reviewed six (6) out of six (6) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. LPA observed six (6) out of six (6) resident files with a pre-placement appraisal but missing an appraisal/needs and services plan. Administrator stated the appraisals will be completed. LPA observed one (1) staff member without first aid/CPR training and without a criminal record clearance transfer. Administrator stated the staff member will complete their training and be associated to the facility. LPA also observed staff training to be completed by Administrator Stepanyan, however, the Administrator does not have two (2) years of experience to provide training. Administrator stated that staff will be re-trained by a qualified trainer. During the visit, LPA obtained copies of valid liability insurance, LIC 500, and resident roster. Continued on LIC-809-C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as required with the last drill conducted on 02/09/2026. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500 for criminal record clearance. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.