Routine inspection·February 20, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:03 AM. LPA met with facility staff member Emma Elazyan (S1) who contacted the facility administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:10 AM, the LPA, along with S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured cabinet to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications and a first aid kit. One (1) additional secured cabinet was observed to contain facility files. LPA observed a cabinet to contain adequate emergency food supplies. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 02/26/2024. COMMON AREAS : This includes the living room, hallway, and dining area. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain a television and activities for resident use. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. LPA observed a hallway closet to contain extra linens. The facility’s fire and carbon monoxide alarms were tested at 09:47 AM. At 09:48 AM LPA observed the facility’s carbon monoxide alarm to be non-functional. All exits in the facility were observed to contain functioning auditory alarms. Continued on LIC 809C. BEDROOMS : There are four (4) bedrooms in the facility; two (2) are a dual occupancy rooms and two (2) are single occupancy rooms. LPA and S1 toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #2’s window was observed to be missing a window screen. Bedroom #1’s window screen was observed to be seated improperly in the frame which left an opening in the corner of the frame. BATHROOMS : There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 138.2 and 140.4 degrees Fahrenheit, which outside of the range required by regulation. The private resident’s bathroom window screen was observed to be seated improperly in the frame which left an opening in the corner of the frame. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain two (2) additional refrigerators containing extra food items. RECORD REVIEW: Record review began at 10:00 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. One (1) staff file was observed to be missing the required LIC 508 Out-of-state disclosure sheet. One (1) staff file was observed to be missing the LIC 503 Health screening report – facility personnel and a negative TB test. Six (6) resident files were reviewed. One (1) resident file was observed to be missing a negative Tuberculosis (TB) test. MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for six (6) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. Continued on LIC 809C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/14/2025. The facility’s emergency disaster plan is adequate. The emergency disaster plan was last reviewed/updated by the Administrator on 06/22/2021 which is outside of the required annual timeframe. The infection control plan is reviewed/updated annually by the facility’s administrator. INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. One (1) staff interview was conducted. The staff member interviewed was knowledgeable on the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. The facility was unable to provide a copy of valid liability insurance at the time of the inspection. The facility Administrator was unable to come to the facility to sign this report but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.