Routine inspection·August 12, 2025

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two (2) staff and six (6) residents present. The LPA was greeted by the Administrator, Anahit Manukyan and the reason for the visit was explained. Entrance interview conducted. Starting at 09:30 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Kitchen: The LPA inspected the kitchen/food service area at 09:32 a.m. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. An adequate amount of emergency food and water was observed; properly stored. At 09:34 a.m., the hot water temperature was measured in the kitchen sink, and it measured at 108.9 degrees Fahrenheit. Common Areas: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed several fire extinguishers to be fully charged with a purchase date of 04/14/2025. Report Continued on LIC 809C... Report Continued from LIC 809... Required postings were observed throughout the common space. Activities were observed in the living room. There is a working telephone on premises. Cameras observed in the common areas. The LPA observed a closet in the hallway with additional clean linens and towels. Emergency exit plans posted throughout the facility. Restrooms: There are two (2) restrooms for resident use and one (1) restroom for staff use only. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 09:40 a.m., the hot water temperature was measured in both bathrooms, and they measured between 116.7 and 118.2 degrees Fahrenheit. Bedrooms: There are three (3) bedrooms for resident use. All bedrooms are designated as double occupancy / shared rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises. Laundry: Washer and dryer were observed in the backyard locked and inaccessible to residents in care. Detergents were observed in a locked cabinets above the washer and dryer at the time of the visit. Outdoors: The backyard has a covered patio area with patio furniture for resident use. The LPA observed a shed for storage purposes. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit. Records: The LPA reviewed six (6) Resident Records and four (4) Personnel Records including the Administrator’s file starting at 09:50am. Report Continued on LIC 809C... Report Continued from LIC 809C... Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order. Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order. Administrator certificate valid until 05/09/2026. During today’s visit, the LPA obtained copies of the client roster, personnel report, and limited liability insurance. Infection Control / Emergency Disaster Planning: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill which was conducted on 06/14/2025. Medications: Medications review began at approximately 11:15 a.m. The medications are locked in a cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. The LPA observed PRN authorization letters on file. Medications are properly documented on the Centrally Stored Medication and Destruction Records (CSMDR). No citations issued. Exit interview conducted. A copy of the report was provided.