Routine inspection·September 16, 2025

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the facility by Kristina Zamkotidou, Staff. Staff contacted Mary Petikyan, Administrator via telephone and she arrived at 11:03am to conduct the visit. The reason for today's visit was explained. The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms, 3 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #1 is designated for bedridden use. The facility is approved for 2 hospice waivers. There are no bodies of water on the premises. During today's visit all 12 domains of the CARE Inspection Tool was reviewed, 5 resident files and 8 staff files were reviewed. A tour of the physical plant, inside and outside, was conducted. The following were observed on today's visit: The dining room, living room and kitchen are equipped/furnished with the appropriate furniture and equipment for it's designated use. Bedroom #1 and Bedroom #4 were observed with 2 hospital beds, 2 night stands, 2 lamps, 2 chairs and a shared dresser. Bedroom #1 has 2 portable closets and Bedroom #4 has a built in closet and a portable closet. The windows and outside exiting doors have blinds for privacy. The auditory devices on the doors were tested and were operational. Located inside Bedroom #4 is a private bathroom equipped continued on LIC809-C Page 2 with a shower, a sink, toilet with a riser, grab bars and a slip resistant mat. Water temperature was tested and read 109.5 degrees Fahrenheit. Bedrooms #2 and Bedroom #3 were observed with 1 hospital bed, a night stand, a lamp, a chair, a dresser and a built in closet. Bedroom #2 has an outside exiting door that leads to a ramp and is equipped with an auditory device and was operational. Located inside Bedroom #2 is a private bathroom equipped with a walk in shower, toilet, a sink, grab bars and a slip resistant mat. Water temperature was tested and read 118.9 degrees Fahrenheit. The common bathroom located by the laundry closet is equipped with a walk in shower, chair, sink, toilet, grab bars and a slip resistant mat. Water temperature taken read 114.6 degrees Fahrenheit. The laundry closet was observed with a stacked washer and dryer. Extra Linens, towels and blankets were observed in the hallway closet. The facility has current general liability insurance that meets Title 2 requirements. The garage was observed to be used for storage of incontinent products, 30 gallons of water, an extra refrigerator with meats, fruits and vegetables and emergency rations and extra wheel chairs, sofa and staff clothing. Sufficient perishable foods for a minimum of days and non-perishable foods for a minimum of 7 days were observed. The facility also maintains 2 buckets of emergency food rations. The facility has 2 fire extinguishers - one located in the dining room and one by the door to the garage. Both were purchased on 4/24/25. The first aid kit met Title 22 requirements. First aid manual was observed. The hardwired smoke detectors located inside the resident bedroom and the combination smoke/carbon monoxide detector located in the resident room hallway and the living room were tested and were operational. However, the fire rated door located between the resident rooms and living room did not shut completely. Per tour of the backyard, a table with an umbrella, chairs and wicker sofa and armchair were observed. Trash cans located along the right side of the home were observed in good condition and were tightly sealed. The front and back yard were observed to be clean of debris except for fallen leaves. continued on LIC809-C Page 3 no bodies of water were observed on the premises. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, Appeals Rights discussed and a copy was provided.