Follow-up on corrections·May 30, 2025

Licensing Program Analyst (LPA) Trevor Byrne conducted unannounced case management deficiencies visit at the facility today. LPA arrived to the facility at 10:15 AM. LPA met with the facility staff, staff #1 (S1) who contacted the facility Administrator Emma Avetisyan via telephone call. The Administrator arrived to the facility at approximately 12:30 PM. Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a physical plant tour to ensure there are no health and safety hazards, collected copies of pertinent documents, conducted a medication audit for one (1) resident, and conducted interviews with the Administrator, one (1) staff member, one (1)resident, and one (1) witness between 10:20 AM and 02:00 PM During the physical plant tour LPA observed the flooring near the exit located in the kitchen to be bubbling up, held together with tape, and in disrepair. Additionally, LPA observed the closet door located in bedroom # 2 to be detached from the railing and in disrepair. LPA observed a light switch cover in the shared resident bathroom to be broken and had sharp exposed plastic. LPA informed the Administrator of the items that were in disrepair and the Administrator agreed to perform the needed repairs to the identified items. During an interview with S1 and the Administrator LPA was informed that resident #1 (R1) was recently hospitalized after a medical incident. LPA reviewed the facility file and their inbox and did not observe an incident report submitted for the hospitalization of R1. LPA informed the Administrator that incidents must be reported to Community Care Licensing Division no later than seven days following the occurrence of the incident. The Administrator expressed understanding and submitted a report for the incident at the time of the inspection. Continued on LIC 809C. During medication review LPA observed R1's medications. LPA observed one (1) medication to not be listed on R1's centrally stored medication and destruction record sheet (CSMDR). LPA informed the Administrator of the discrepancy. The Administrator agreed to conduct a medication audit and submit an accurate CSMDR for R1 to CCLD. During file review LPA observed the resident file for resident #2 (R2). LPA observed this resident’s physician report to identify the resident as “Ambulatory” and “Able to feed self”. During the visit LPA observed R2 to be utilizing a wheelchair and being fed by S1. LPA asked the Administrator about the condition of R2. The Administrator confirmed that R2 was a Non-Ambulatory resident based on their physical condition and mental diagnosis. The Administrator stated that this is a recent change of condition, and the facility had not yet obtained an updated physician report for the change in condition. LPA informed the Administrator that the facility’s fire clearance does not allow them to accept or retain Non-Ambulatory residents. LPA informed the Administrator that this is a violation of their fire clearance and poses an immediate safety risk to clients in care. LPA informed the Administrator that this is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (05/30/2025). The Administrator expressed understanding and confirmed that they will contact the local fire department and notify them that they have a Non-Ambulatory resident. Additionally, the Administrator confirmed that the resident would be relocated to a licensed facility that has an appropriate fire clearance to care for Non-Ambulatory residents. During the file review for R2 LPA observed R2’s physician’s report to be missing a negative TB test. LPA asked the Administrator if they were able to provide proof of a negative TB test for the identified resident. The Administrator stated that the physician’s report was transferred from another facility and the facility had not yet obtained an updated physician report for R2. LPA informed the Administrator that they were recently cited for a violation of CCR 87458(c)(1)(A) on 02/20/2025. LPA informed the Administrator that this is a repeat violation of the same regulation within a 12-month period and a civil penalty in the amount of $250 will be assessed on today’s date (05/30/2025) for a repeat violation. The Administrator was unavailable 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 and civil penalties were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.