Routine inspection·August 14, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:20AM. The LPA met with Staff #1 (S1) and Staff #2 (S2) and explained the reason for the visit. S1 contacted Administrator Aleksandra Vartapetova who was unavailable and designated S1 to conduct the visit and sign today’s report. Entrance interview conducted. Beginning at 9:33AM, the LPA and S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility is a single story residential home. The following was observed: COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The dining room had a screened and inoperable fireplace. Required postings were located on the entryway wall. The entryway hallway had two (2) closets: one (1) was locked and contained resident medications and one (1) closet contained files and storage. The facility maintained a comfortable temperature throughout the visit. The facility had a laundry room connected to the kitchen and LPA observed the machines to be in good condition. KITCHEN: The LPA observed knives stored inaccessible in a locked drawer. Additional knives and scissors were observed in unsecured drawers and S1 secured them. Cleaning supplies were stored inaccessible and locked under the sink. Kitchen appliances were clean and in operable condition. Report Continued on LIC 809-C The facility had one (1) drawer with the front panel broken, leaving nails exposed. The facility had a supply of perishable and non-perishable food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. LPA observed S1 stored their refrigerated medication that was accessible to residents. Staff personal belongings were stored in a locked cabinet. Two (2) medication bottles were observed in two (2) drawers that belonged to S1. S1 secured their medications. One fire extinguisher was observed and was purchased on 05/16/2025. BEDROOMS/RESTROOMS: There were six (6) total bedrooms, each designated as private resident bedrooms. Bedrooms #2, #3, #4, #5, and #6 had direct exits to the outside. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in cabinets located in the hallway. There were seven (7) total restrooms in the facility: four (4) attached private resident restrooms, one (1) shared resident restroom located in the hallway, one (1) restroom designated for staff and visitors located in the entryway, and one (1) restroom located in the office. Restrooms were clean, sanitary, and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. LPA observed two (2) bleach bottles under the staff/visitor restroom sink and S1 secured the bottles. The shared resident restroom was observed to have a ripped window screen. Hot water was tested and measured between 123.1 degrees F and 128.3 degrees F, which is not within the required range of 105 degrees F and 120 degrees F. Additionally, LPA observed the restroom in Bedroom #4 was remodeled; S1 confirmed the facility was in the process of remodeling. No notification was provided to Community Care Licensing. OUTDOOR AREA: The surrounding grounds had one (1) shaded patio area equipped with furniture in good condition for resident and visitor use. LPA observed a properly fenced and secured in-ground pool in the rear yard. There were two (2) emergency exits located on each side of the facility that led to the front yard. One (1) of the side exits was obstructed by garbage bins, a water hose, a cordless vacuum, and a portable toilet. Report Continued on LIC 809-C LPA observed three (3) windows did not have a window screen and one (1) window screen was not properly secured. Additionally, the LPA observed an ethernet cable hanging from the gutters that led into a window. The hanging ethernet cable obstructed one third of the perimeter’s passageway. The front yard had a driveway with a self-latching gate. The front yard also had a water fountain that did not contain any water. The facility had a designated office space that was locked and contained an office, storage, emergency food and water, and extra food. The extra food observed in the refrigerator and freezer were good quality. RECORDS: Record review began at 10:20AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA observed S2’s Health Screening report was falsified as it was a copy of S1’s report. S1’s Health Screening report was dated 10/03/2019. S2’s Health Screening was also dated 10/03/2019 with the Physician’s signature date to be written over stating 10/03/2020. S1 was hired on 08/20/2019 and S2 was hired on 10/05/2020. Four (4) out of five (5) staff files did not have a current first aid/cpr training with expired training ranging from 07/11/2021 to 07/24/2025. S1 contacted secondary Administrator Evelina Vartapetova who could not provide updated documentation. Staff #3 (S3) was also confirmed as an Administrator, but did not have an Administrative Certificate. Administrator Evelina Vartapetova’s file was not found. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA was unable to review the facility's infection control plan and emergency disaster plan and staff were unable to locate the documents. S1 contacted Administrator Evelina and stated it was just done, however staff were unable to provide the LPA the documents. Report Continued on LIC 809-C Administrator Evelina asked for time and offered to email the documents to the LPA, however the LPA explained that if there was a current emergency, staff are unable to follow proper emergency protocols because the plans were nowhere to be found. Emergency disaster drills were allegedly conducted quarterly, however the facility could not provide documentation. Smoke and carbon monoxide detectors were tested at 10:09AM and were operational. MEDICATIONS: Medication review began at 11:34AM. Medications were centrally stored and kept inaccessible in the entryway. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were not properly documented on the centrally stored medications and destruction record (CSMDR). Resident #1 (R1) had nine (9) prescribed medications and eight (8) medications were not documented. R1’s CSMDR provided was dated 07/16/2025 and R1’s current medications were filled on 07/16/2025, 07/28/2025, and 08/11/2025. R1 also had one (1) PRN (as needed) medication and the facility did not have a PRN Authorization Letter. Resident #2 (R2) had four (4) prescribed medications with one (1) medication properly documented. The one medication was filled on 04/27/2025; S1 stated R2’s son refills the medications and brought the medication in with the same bottle to the facility. The remainder of the medications were filled on 08/04/2025 and 08/07/2025. R2’s CSMDR most recent update was on 07/08/2025. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). LPA reviewed the report and citations with Administrator Aleksandra Vartapetova via telephone call. S1 was designated to sign the report. Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.