Routine inspection·July 2, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 8:55AM. The LPA was greeted by Staff, informed them of the reason for the visit, and Staff proceeded to notify the Licensee. The Licensee Sargis Ayvazyan arrived at 9:58AM. Entrance interview conducted. Beginning at 10:30AM, the LPA and the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: Knives were stored inaccessible in a locked drawer near the dishwasher. Cleaning supplies were located under the sink in a locked cabinet. Kitchen appliances were clean and in operable condition. Food in the refrigerator was observed to be properly stored with labels and dates. Emergency food and water was located in a cabinet above the refrigerator. Hot water was tested and measured at 118.6 degrees F. LPA observed one (1) fire extinguisher that was purchased on 07/11/2024 and a first aid kit mounted on the wall. Report Continued on LIC 809-C COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The living room had an office area which contained locked file cabinets and a mini fridge that contained medications. LPA observed night lights throughout the facility. The facility maintained a comfortable temperature throughout the visit. Grab bars were provided in the hallway for residents’ use as needed. Also located in the hallway was a laundry closet that was observed to be operational. Locked hallway cabinets contained detergent and general cleaning supplies. BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each with dual occupancy. Bedroom #1 had a direct exit to the outside and is cleared for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinets. There were two (2) total restrooms in the facility: one (1) shared common restroom and one (1) private restroom located in Bedroom #3. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Both restrooms had locked cabinets under the sink that stored extra towels or cleaning supplies. Hot water was tested and measured between 115.2 degrees F and 119.8 degrees F. OUTDOOR AREA: LPA observed a grill, and one (1) patio area equipped with furniture for residents and visitors to use. There is one (1) front door gate and driveway gate used for emergency exits and it is remote and manually operated. No bodies of water noted, and exits are free of obstructions. LPA observed one (1) shed that contained general storage and outdoor equipment that remained locked. Report Continued on LIC 809-C RECORDS: Record review began at 10:58AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. LPA observed four (4) out of six (6) residents did not have an Appraisal/Needs and Services Plan on file. The Licensee stated the Appraisals are not required due to the verbiage of the documents, to which the LPA and Licensee had a discussion on the regulations and reviewed current forms. One (1) out of six (6) residents did not have a Physician’s Report or TB test. The Licensee stated they will obtain the resident’s Physician Report from their previous nursing facility. The LPA discussed with the Licensee the use of common area cameras and advised that they update residents’ Admission Agreements with an Addendum stating the use and knowledge of cameras. LPA advised the Licensee to update their Plan of Operation as well regarding the use of cameras. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medication review began at 2:37PM. Medications were centrally stored and kept inaccessible in cabinets located near the dining room and hallway. Medications were observed for three (3) residents. Medications are labeled and checked for expiration dates. LPA observed Resident #1 (R1) was prescribed two (2) PRN Medications (Senna 8.6MG and Quetiapine 50MG) and it was not documented when Staff administered them to R1. Additionally, R1’s PRN Authorization Letter authorized the administration of Quetiapine 50MG, but did not list Senna 8.6MG. The Licensee obtained an updated PRN Letter before the conclusion of the visit. The Licensee stated that the facility is in the process of working with their Pharmacy to obtain updated Centrally Stored Destruction and Medication Records (CSDMR) and that four (4) out of six (6) residents did not have a CSDMR. Report Continued on LIC 809-C The review of Resident #2 (R2) revealed that nine (9) out of twelve (12) of their medications were not documented on their CSDMR. Additionally, R2 did not have a PRN Authorization Letter and the Licensee stated they would obtain it. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, the LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 05/14/2025. Smoke and Carbon Monoxide alarms were tested at 3:55PM and were operational. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of today's report and appeal rights were reviewed and provided.