Routine inspection·November 26, 2025

At 9:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with Ainura Amanzholova, Caregiver, who granted access to the facility. The Administrator Marine Grigoryan was contacted via a telephone and LPA explained the reason for the visit. The Administrator arrived at the facility at 10:00 AM. Administrator designated the caregiver to conduct the physical plant tour of the facility with LPA. LPA was informed that the facility currently has six (6) residents, of which three (3) residents are non-ambulatory. Three (3) residents are currently on hospice. Facility has waiver for six (6) hospice residents. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, and a sink. Stove was observed in a good working condition. At 9:10 AM, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a locked box and inaccessible to residents. LPA observed a Fire Extinguisher and was last purchased on 11/18/2025. It was observed hanging on the kitchen wall. MEDICATION ROOM: The centrally stored medication are kept in the in the locked cabinet by the dinning area. Residents and staff files will be kept in the same cabinet locked and inaccessible to residents. BEDROOMS: There are six (6) bedrooms designated for resident’s use. All bedrooms are private. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. The facility will have an awake staff. Auditory alarms were tested and observed to be operational. Continue on LIC 809C BATHROOMS: There are three (3) bathrooms at the facility. L PA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat The water temperature was noted at 113.4°. LAUNDRY ROOM: The laundry room is located in the hallway by bedroom # (6). All the cleaning supplies and laundry detergents will be kept locked in box in the facility storage area in the backyard. The washer/dryer were observed in working condition. COMMON AREAS: The facility maintains a comfortable temperature at 74°F. The living room and dining area appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPA observed a working telephone for the facility. SURROUNDING GROUNDS: The facility has sufficient backyard space. LPA did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) residents, LPA observed a covered shaded area for residents. LPA observed inside and outside activities for residents in care. There is no swimming pool or any bodies of water at the facility. LPA observed a garage/storage area with PPE supplies and was observed locked an inaccessible to residents in care. The exit was free of any obstruction or hazard. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 9:35 AM, they were tested and observed to be operational. Between 10:45 AM to 12:45 PM, LPA reviewed records of six (6) residents and two (2) staff records. LPA observed that all six (6) residents file documents (consent forms, ID and emergency information, Appraisal Needs and Services Plan, LIC 613C personal rights and etc,) were missing signatures. On 08/06/2025, R3 was taken to the hospital Emergency Room (ER) for Fecal Impaction in Rectum, and on 10/21/25, R3 was taken to the hospital ER again for abdominal pain; however, no incident reports were submitted to Community Care Licensing (CCL) in a timely manner. Additionally, Administrator failed to provide a proper pre-assessment and accepted R3 with prohibited health condition and after accepting R3 no proper training were conducted with staff members. LPA also observed R6's file was missing TB test results. Due to the time constrains LPA will conduct a continuation of the annual inspection on another date to issue deficiencies and review medication. Exit interview conducted and copy of this report signed and provided.