Routine inspection·July 20, 2023

Licensing Program Analyst (LPA) Angel Ascencio conducted a required annual to the above facility. LPA Ascencio met with staff at 09:45 a.m. Administrator Sargis Ayvazyan arrived shortly after. Entrance interview conducted. The LPA toured the physical plant areas inside and outside at approximately 10:00 a.m. to ensure that there are no health and safety hazards. KITCHEN: At 10:05 a.m., the LPA toured the Kitchen. Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. LAUNDRY: At 10:10 a.m., the LPA observed the laundry area which is located in the hallway closet. Appliances were clean, sanitary and in operable condition. Laundry detergents and chemicals were observed to be locked in an adjacent cabinet in the hallway. BEDROOMS: There are three (3) bedrooms designated for resident use. Bedroom #1 is single occupancy with no private bathroom and an exit to the exterior. Bedroom #1 is approved as bedridden room. Bedroom #2 and bedroom #3 are double occupancy with no exit to the exterior. Bedroom #3 has a shared bathroom. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Storage space cabinet in hallway was observed containing clean linens for resident use. Continued on LIC 809-C. BATHROOMS: Resident bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Bathroom hot water measured between under 120 degrees F. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The LPA observed a locked storage unit containing home improvement materials such as paint. COMMON SPACES: The common spaces included the living room and dining area. The LPA observed cameras in the common areas. A TV for resident use including games in a storage cabinet. All common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. Medications were observed to be locked in a cabinet in the kitchen and contained at least 30 days of worth of medication. INFECTION CONTROL : There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective 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 does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate. Continued on LIC 809 - C The following was observed during today's visit: At 11:20 a.m., during resident file review, LPA observed Resident #1's (R1) LIC 602 Physician's Report indicate an ambulation status of Bedridden. Upon further review, LPA observed the Fire Clearance Inspection Form and observed that the facility is approved for one (1) bedridden room that has an exit. The bedridden room is located in Room #1. R1 is currently located in Room #3. A civil penalty of $500.00 was assessed. Additionally, LPA Ascencio did not observed the Needs and Service Plan/Appraisal for six (6) out of 6 residents. Also, R2 did not have Tuberculosis test result on file, and 6 out of 6 residents did not have PRN Authorization Letter. LPA Ascencio could not conduct a medication audit as the Centrally Stored Medication and Destruction record was not up to date and the pill count was off. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator authorized staff to sign today's documents. Exit interview conducted and a copy of the report and appeal rights were issued.