Routine inspection·June 12, 2025

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. When the LPA arrived, there was one staff present. The LPA was greeted by Caregiver, Armenuhi Ahadzhanian and informed the reason for the visit. Caregiver contacted the Administrator by phone, Sofia Ghazaryan. At 10:17 A.M. administrator arrived at the facility. LPA explained the reason for the visit. At 10:25 A.M. the LPA, along with administrator, 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 following was observed. Facility is a single-story residence that consists of four (4) resident bedrooms and two (2) bathrooms. There is one (1) additional bedroom and bathroom for staff use. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Bedrooms: All resident resident’s bedrooms were properly furnished with at least one chair, a bed, night stand, chests of drawers, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Continued on LIC 809-C Continued from LIC 809 Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The LPA observed grab bars and slip resistant floors in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. Between 10:31 A.M. and 10:45 A.M. hot water was measured in all residents’ bathrooms. All bathrooms were within the required limit of 105-120 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 74 degrees. The LPA observed the required postings in the entry way and common sitting area. Combination smoke alarms and carbon monoxide detectors were tested at 3:02 P.M. and were operational at this time. LPA observed a fully charged fire extinguisher serviced on 10/23/2023. Technical violation issued under maintenance and operations. LPA observed cameras in common areas. Kitchen : The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects were stored in a kitchen drawer located to the right of the oven. During today’s visit, the magnetic lock on the drawer was not functioning properly and failed to keep drawer securely locked. The administrator stated that the lock is malfunctioning and acknowledged that it needs to be replaced. Furthermore, LPA observed a glass cup containing stainless steel knifes stored inside an unlocked kitchen cabinet. Additionally, an unlocked medication injection was observed inside the kitchen refrigerator. At 10:53 A.M. hot water measured at 105.7 degrees Fahrenheit. Garage: The facility has converted the garage into a separate living space which has its own address. Continued on LIC 809-C Continued from LIC 809-C Surrounding Grounds (Outdoors) : The backyard has a covered outdoor area equipped with furniture for resident use and a small laundry area. There were no bodies of water noted. The front yard is free of obstructions, the side gate has a self-latching door. Additionally, the LPA observed a back house with two (2) rooms. Upon entering the first room, the LPA observed that it was being used as an office and storage area. The room contained extra food supplies, a refrigerator, and emergency food and water provisions. LPA conducted a review of expiration dates on product labels. The LPA observed that three (3) items were past their expiration date. Administrator discarded all three (3) items during today’s visit. Technical Advice Issued. The second room was locked, however, upon entry, the LPA observed that it contained chemical supplies, tools, and various decorations. File review: A review of facility files was initiate at 11:23 A.M. and the following was observed. LPA reviewed five (5) of five (5) residents files and three (3) staff file including the administrator’s. Files were reviewed for, but not limited to: Physician's Reports, Personal Rights, Admission Agreements, staff training records, health screenings, TB tests, and background clearance. Record review of resident files revealed that Resident #1’s (R1)’s physicians report, dated 02/04/2024 indicating R1 not having capacity for selfcare and R1 is neither under hospice care nor have an approved exception on file with the Department. Furthermore, LPA observed that of the five (5) residents currently residing at the facility, three (3) are non-ambulatory, one (1) is bedridden and one (1) is ambulatory. Continued on LIC 809-C Continued from LIC 809-C The facility’s fire clearance on file, dated on 01/05/2016, only authorizes care for four (4) ambulatory residents, one (1) non-ambulatory and one (1) bedridden resident. According to the clearance, only Room #3 is approved to accommodate residents who are non-ambulatory or bedridden. During the plant tour, LPA observed that bedridden resident (Resident #1 -R1) was placed in room #2, non-ambulatory resident (R2) was placed in room #1, and Resident #5 (R5) was placed in the former activity room which are not designated for such use. The Administrator stated that a new fire clearance was granted in 2023, however, she was unable to present the document at the time of the visit. LPA attempted to contact the fire inspector to verify the updated clearance but was unable to confirm this information. Also, LPA observed R3 did not have a current hospice care plan on file. Additionally, R2 and R3 were observed to have full bed rails installed on their beds, however, there were no physician’s orders were on record. Administrator was able to provide this information during today’s visit. Furthermore, R1, a former hospice patient who is no longer under hospice care was observed to have f ull bed rails in place. No current physician’s order was available to support the continued used of the full bedrails. During staff record review, LPA observed that Administrator (Ad), Staff #1 (S1) and Staff #2 (S2) did not have current CPR/First aid certificate. The administrator is the SSI payee for R1 and surety bond is current. LPA requested last emergency drill; however, Administration was unable to provide it. LPA obtained Client Roster, Personnel Report, liability insurance and updated facility Sketch. Continued on LIC 809-C Continued from LIC 809-C Medication Audit: Medications review began at 3:24 P.M. medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. LPA observed errors during the medication review where date started and pill count did not match. 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. An immediate civil penalty of $500 is assessed today due to being cited for fire clearance. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.