Routine inspection·March 8, 2022

Licensing Program Analyst (LPA) Jewel Baptiste conducted an annual inspection visit at the facility with focus on the infection control domain, food, and medication review. LPA Baptiste met with Narine Hannesyan administrator and explained the reason for the visit. Upon arrival LPA observed administrator and staff#3 with out mask or face covering. Staff#3 is observed not associated and living at the facility. Facility is licensed to serve 6 over the age of 60 years old, which 6 non- ambulatory, of which 1 maybe bedridden. Facility has a hospice wavier for 3. At the time of inspection facility census is 5. Facility is located in a residential neighborhood, single story house, living room/ dining room, kitchen, 4 bedroom, 1 staff bedroom, and 2 bathrooms one of which is located in bedroom #2. LPA conducted file review of administrator and staff #1. During the review LPA observed administrator certificate expired 3/31/2021 and CPR card expired 9/2020. Staff #1 was missing employee rights. LPA conducted file and medication review for resident #1, #2 and #3. Resident #1 file was missing pre-appraisal, needs and service and functionality form. Resident #2 physician report was blank, pre-appraisal and needs and service, and capability and functional form was missing. Resident #3 did not have physicians’ orders for medications. Resident #3 file was missing, pre-appraisal, needs and service, and capability and functional form was missing. continued on 809c LPA and administer conducted tour of the facility together and observed the following: Kitchen area has sufficient food worth 2 days of perishables and 7 days of non-perishables. All bed rooms has sufficient lighting, furniture, and all the required bedding Bathrooms were observed with skid mats built into shower and grab bars. Water temperature was tested between 106.4- 106.5 degrees F, which is within the required 105-120 degrees F. LPA observed COVID-19 signs posted through out the facility, bathrooms observed with soap, signs and paper towels. Screening conducted for residents, staff and visitors. LPA observed PPE supplies for at least 30 days. Per administrator N95 fit testing was conducted for all staff. LPA observed fire extingusher is fully charged and dual units with carbon monixide detectors built in, they were tested and in working order. There were deficiencies found during today’s inspection. Deficiencies are cited from California Code of regulations, Title 22 and/or H&S Code 1569() and citations are listed on the attached LIC809D. If the deficiencies are not corrected by the noted due date, civil penalties may be assessed. Exit interview conducted, appeal rights provided, and copy of report left at the facility.