Non-compliance follow-up·May 16, 2025

At 9:30am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced Case Management- Legal/Non-compliance visit. Upon arrival LPA met with the Caregiver Gayane Nersesyan, showed the department badge and explained the reason for the visit. Administrator Gayane Aghabekyan arrived shortly after and helped with physical plant walkthrough and resident/staff files. Entrance interview conducted. On 7/30/2024, a Non-Compliance Conference (NCC) was held at the Regional Office (RO) to discuss complaint # 31-AS-20211116143735 and other facility deficiencies. Attendees included Regional Manager, Angela Whittaker; Licensing Program Manager, Eva Miller; Licensing Program Analysts Perchui Milena Khurshudyan, Mariana Agban, Licensee Bagrat Vahramyan, Administrator Gayane Aghabekyan, and Administrator Designee Rima Agaronyan. As a result of that NCC, the facility was placed on a two-year compliance plan. At that time, Regional Manager (RM) and Licensing Program Manager (LPM) advised the Administrator should strive to remain in full compliance Relevant Title 22 Regulations. The purpose of today’s visit is to conduct thorough inspection to ensure compliance. LPA conducted a physical plant tour to ensure the health and safety of the clients and that the physical plant was in compliance with CA Title 22 Regulations. Today’s focus was staff and resident records for accuracy, required documentation for Exception Requests, Residents health condition. Continue on LIC809-C At approximately 10:15am, LPA requested staff and resident records. LPA was informed that the facility currently has five (5) residents and five (5) staff members. During today's visit LPA observed two (2) staff members on duty. LPA also checked the Licensing Information System (LIS) and observed that staff members/Caregivers are associated with this facility and the fingerprints are cleared. LPA interviewed all residents, and all residents confirmed they feel happy, they love the facility, and have no concerns regarding food, staff and/or the care they receive in the facility. Resident Files: At 11:00am LPA conducted resident and staff records review. The following was observed. Five (5) out of five (5) residents’ files were updated and complete. All required forms were present. Staff Files: The Administrator stated that the facility currently has five (5) staff members. LPA observed all files were complete and updated. Medication: LPA checked centrally stored medications stored locked inside the commercial cabinet located in the office area. All medications have Physician’s orders. Facility was in compliance, thus, no deficiencies were identified and issued during today’s visit. Exit interview conducted, copy of this report signed and delivered.