Routine inspection·May 17, 2024

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff and explained the reason for the visit. The Licensee / Administrator Siranush Alvadzhyan arrived shortly after. The LPA 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. LPA inspected facility for fire safety, personal accommodations, and food service. The facility smoke alarm and combined carbon monoxide system is hard wired and was functional during the inspection. The fire extinguisher was observed to be fully charged and last purchased in 03/29/2024. LPA inspected kitchen at approx. 10am, Knives are kept inaccessible in  lock boxes on the counter to the right of the fridge.   Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning products were observed stored inaccessible to residents in care. Emergency food was observed to be sufficient and stored in bottom cabinet to the right of the fridge. The common areas were appropriately furnished, and the lighting was adequate. There are games and/or activity supplies in the living room.   There was sufficient space to accommodate indoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. LPA observed medication, residents and staff records to be kept inaccessible in locked cabinets to the left of the fridge. LPA observed required postings throughout the common spaces. The bedrooms were observed to be properly furnished with a bed, night stand, and sufficient lighting for each client The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Continued from 809 LPA observed bathroom to be clean, properly supplied and had functional fixtures. The hot water was measured in the bathrooms within 105 - 120 degrees Fahrenheit. The bathrooms were sufficiently stocked with supplies and paper towels. In the front lot of the facility, LPA observed a shaded patio with furniture designated for outdoor use.  There were no bodies of water noted. The facility has one (1) shed in the backyard that is utilized for additional storage of cleaning supplies, furniture and other items for facility use. There is sufficient room to conduct outdoor activities. The exterior passageways were clean and clear of any obstructions. There is an additional structure in front of the facility that is being rented by independent individuals who do not require care and supervision. There is no backyard or bodies of water. The property is completely fenced and gated with access out of the property through a sliding gate and individual door located at the front of the driveway. There is no garage. Records review began at approx 10:30am, client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.  All records were observed to be in order at this time.  Last emergency disaster drill was conducted 04/26/2024. Medications review began at approximately approx. 11:30am. Medications were observed to be properly documented on the centrally stored medications and destruction record at this time. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed to be stored inaccessible in the medication cabinet as well. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time. During the visit, LPA interviewed staff and residents. LPA also obtained the following documents - Updated Limited Liability insurance. Exit interview conducted and copy of report issued.