Routine inspection·February 4, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Asmik Avestisyan and explained the reason for the visit. The facility is licensed to served (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a single home located in a residential neighborhood and consist of a living/dining room area, a kitchen, (4) resident bedrooms, (4) resident bathrooms, (1) staff/visitor's bathroom, a front porch, a backyard, and a detached garage. LPA toured the facility with Asmik Avetisyan and observed the following: Facility is in good repair indoor and outdoor. All passageways are free of debris. There are no large bodies of water. Living room and dining room are furnished to provide seating area and activities for the residents. Activities were observed in the living room. Kitchen was observed clean and in working condition. There is sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies, sharps and medications are kept locked in kitchen cabinets. Four (4) resident bedrooms were observed with sufficient lighting, the required furniture, and bedding supplies. A total of (4) bathrooms were observed in working condition, with grab bars and skid mats. Water temperature was tested in each bathroom between 106.8-116.7 degrees F., which is within the required 105-120 degrees F. Carbon monoxide/smoke detectors were tested and are in working condition. Fire extinguisher was observed and last reviewed on 1/14/25. All requires posters were observed. Facility has a porch that provides a shaded area as well as a clean backyard. Laundry is located in the basement. Exit doors have an auditory device. LPA reviewed medication and files for 3 residents. There are currently zero (0) residents on hospice or with dementia. Resident #3(R3) is missing a TB test clearance. Bed rails were observed in the beds of Resident #1and #3 (R1/R3), no physician's request on file. (CONTINUED ON LIC 809C) LPA reviewed 2 staff files. Administrator's file was not at the facility at the time of the visit. Staff #3(S3) was missing TB clearance results on health screening, physician noted read date but did not note results. S3 was hired on 1/5/25 and has been working since January 14, 2025, there are no records of fingerprint clearance. Administrator certificate was reviewed for Sako Manvelyan #6066207740 exp. date: 9/8/25. LPA Flores reviewed infection control plan and emergency disaster plan. Last fire drill was conducted on 12/16/24 and are being conducted quarterly. Deficiencies are noted on LIC 809D per Title 22 Regulations. *Civil penalties were assess for $500.00 for background clearance.* Exit interview was conducted with Administrator and a copy of this report, LIC 809D, and appeal rights were provided.