Routine inspection·December 2, 2023

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Hakob Gevorkyan and explained the reason for the visit. The facility is licensed to served 6 non-ambulatory residents age range 60 and over, of which 1 may be bedridden and hospice waiver for 6. The facility has 6 bedrooms, 1 bathroom, a dining room, a living room, a detached garage, a detached laundry room, back patio and a front yard. LPA Flores conducted a tour of the facility with Hakob Gevorkyan and observed the following: Facility is in good repair inside and outside. Living and dining area are clean and have sufficient sitting area for activities. Kitchen is clean, food was observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Sharps were observed locked on a drawer and cleaning supplies were observed locked under the sink. Resident's rooms (6) were check and each has sufficient lighting, furniture, and bedding supplies. Bedroom #1 has a covered fireplace. Bathroom was observed with skid mat, grab bars and water temperature was tested at 86.3 degrees F., which is not within the required 105-120 degrees F. Garage is used for storage of emergency food supplies and infection control supplies. The backyard was observed clean and has a shaded seating area. Interlace smoke/carbon monoxide detectors were tested during the visit and in working condition. LPA did not observed PUB745 - Let us know poster posted at the facility. Fire extinguishers were observed and last checked on 10/19/23. LPA reviewed medication and files for 5 residents. Resident #4(R4)'s medication was observed without prescription labels and out of the original container. Resident #3(R3) did not have a pre-appraisal on file. LPA reviewed 5 staff files and no record of initial or annual training was observed in files for staff #2-5(S2-S5). LPA reviewed infection control plan which was last reviewed on 7/1/22 and disaster emergency plan which was last reviewed on 6/1/21. Last fire drill was conducted on 10/1/23. (CONTINUED ON LIC 809C) Administrator certificate was posted for Nvard Gevorkian#6050643740 and exp. on 12/23/24. No record of designee letter was observed and facility has assigned staff #4 and #5 as the designee staff. LPA interviewed 2 staff and 2 residents. Deficiencies were noted during this visit on LIC 809D per Title 22 Regulations. Exit interview was conducted with Nvard Gervokian administrator and a copy of this report, LIC 809D, technical violations, and appeal rights were provided.