Routine inspection·April 4, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual inspection. LPA arrived at the facility at 9:25AM, met with the facility Licensee Zhanna Davtian and explained the purpose of the visit. LPA Huynh and Licensee conducted a tour of the physical plant at 9:30AM to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. 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 facility maintained a comfortable temperature throughout the visit. Smoke and carbon monoxide detectors were tested at 9:40AM and were operational. The fire extinguisher was fully charged and purchased on 02/24/2025. The LPA observed required postings on hallways and night lights throughout the facility. KITCHEN: Knives are stored inaccessible in a drawer under the sink. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator were stocked with a variety of foods. Prepared foods were safely covered with lids and labeled appropriately. Report Continued on LIC 809-C GARAGE: An adequate supply of emergency food and water supply for six residents and two staff were observed in the garage, which is locked at all times. Facility files and medications are stored in the garage and are locked. BEDROOMS: The facility has three bedrooms; Room #1 is shared, Room #2 is private, and Room #3 is shared and cleared for non-ambulatory residents. Bedrooms were furnished appropriately with sufficient lighting and an extra supply of bed linens stored in the hallways. BATHROOMS: There are two bathrooms; one in Room #3 and one designated for shared resident and visitor use. Residents’ bathrooms were observed to be in clean condition with grab bars and non-skid mats available. Hand washing signs were displayed, and sufficient amounts of soap and paper products were supplied in each restroom. Hot water temperature was measured at 113.6 degrees F, which is within the required range. OUTDOOR AREA: Backyard has a shaded patio equipped with outdoor furniture in good condition for residents’ use. There is one automated driveway gate for vehicles and one entry/exit gate. RECORDS: Records review began at 10:00AM. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, 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. All files were in order. Report Continued on LIC 809-C MEDICATIONS: Medications review began at 11:15AM; medications are centrally stored and kept inaccessible in the garage. Two out of six residents’ medications were reviewed. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL/EMERGENCY DISASTER PLAN: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. LPA reviewed the facility’s infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually. Emergency disaster drills are conducted quarterly, with the last drill documented on 02/01/2025. One staff and one resident were interviewed during today’s visit. No complaints noted. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.