Aaa Quality Residential Care Facility

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and explained the reason for the visit. The Licensee Ovsanna Khayalyan arrived to the facility shortly thereafter. The LPA, along with the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The common area was observed to be clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and purchased on 03/18/2026; fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallways and passages. All exits have functioning auditory devices and were operational at the time of the visit KITCHEN: The kitchen/dining area was observed to be clean and propertly furnished. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 107.9-degree Fahrenheit. Medications are located in a locked kitchen cabinet. BEDROOMS: The facility is a single-story residential home with three (3) bedrooms. Bedrooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C… RESTROOMS: Restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid mats. Hot water 106.6-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. There are a washer and dryer located in the staff's restroom. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the staff restroom. The first aid kit was observed in the staff’s restroom. OUTDOOR SPACE: The patio has patio furniture and patio umbrella to provide shade for residents’ use. There is a gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. There are no bodies of water on the premises. RECORDS: Records review began at 12:15 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. All files were in order. MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Certificate Of Liability _ Emergency Disaster Plan No deficiencies were cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 27, 2026

Allegation investigated: Resident sustained unstageable pressure injury.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Urena met with the Administrator Ovsanna Khayalyan and explained the reason for the visit. On 01/31/2025, the Woodland Hills Adult and Senior Care Regional Office (RO) received a complaint alleging facility employees at the AAA Quality Residential Care Facility failed to provide an appropriate level of care to Resident #1 (R1) resulting in R1 developing numerous pressure injuries with one being identified as unstageable. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Douglas Real. Continues on LIC 9099C... Unsubstantiated Page 2. On 02/05/2025, from 10:05am to 12:45pm, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial visit to investigate the allegation listed above. LPA Urena was greeted by staff and informed of the visit. The staff contacted the Administrator Ovsanna Khayalyan via telephone to inform them of the visit. The Administrator arrived at 10:45am and the LPA explained the reason for the visit. The LPA requested records pertinent to the investigation at 10:55am and interviewed the Administrator from 11:09am to 11:57am. The Administrator was advised that the complaint was referred to the Investigations Branch (IB); however, an IB investigator had not yet been assigned as of the visit date. The LPA determined further investigation was needed prior to issuing findings. On 02/24/2025, at approximately 11:55am, Investigator Real conducted interviews with Kaiser Permanente Hospital Social Worker; on 02/25/2025, from approximately 8:45am to 12:30pm, with County of Los Angeles Deputy Public Guardians; on 03/14/2025, at approximately 11:00am, with facility resident; on 04/15/2025, from approximately 10:00am to 1:00pm, with Staff #1 (S1), Administrator, and facility residents; on 05/22/2025, from approximately 11:45am to 1:15pm, with Los Angeles Police Department (LAPD) Detective and Sunshine Care Hospice Administrator; and on 05/29/2025, at approximately 12:00pm, with Sunshine Care Hospice Registered Nurse. In addition, Investigator Real reviewed Kaiser Permanente Hospital medical records, Los Angeles Public Guardian (LAPG) conservator court documents, Sunshine Care Hospice Records, and facility file documents related to the investigation. Due to the complaint was not reported to the LAPD as a crime report, a police report was not generated. Therefore, no investigation or interviews were conducted by the LAPD. According to R1’s Physician’s Report, dated 07/29/2024, the report indicated R1 was diagnosed with Type II diabetes, atrial fibrillation, hypertension, and dementia. R1 was noted as having lower leg diabetic wounds. R1 was admitted to the facility on 07/30/2024. Continues on LIC 9099C page 3.... Page 3. A review of the Sunshine Care Hospice records revealed on 11/30/2024, R1 was placed on hospice with the primary diagnosis of Unspecified Protein-Calorie Malnutrition and the Secondary diagnosis as Senile Degeneration of the brain. The hospice certification period was listed as 11/30/2024 to 02/27/2025. Frequency of visits was noted as home aide 2 times per week, LVN 1 time per week, and RN every 2 weeks. The Department’s investigation revealed R1 was under hospice care while residing in the facility and hospice was aware R1’s health was declining. According to R1’s hospice nurse, they saw no evidence to suggest that R1’s decline in health was due to neglect or abuse by the facility and believes R1’s decline was due to advanced dementia and possibly other comorbidities. R1’s hospice nurses instructed the facility caregivers to turn R1 every two hours, and the hospice nurse had no reason to believe the facility staff did not do so. R1 had a very poor appetite and frequently refused to eat or drink. This behavior likely contributed to R1’s skin breakdown leading to the unstageable pressure injury and the beginning of injuries on R1’s feet. Wound care was ordered through hospice to address the skin breakdown issues and an initial wound assessment was done on 01/29/2025, the day prior to R1 being sent to the hospital. The facility staff denied the allegation and reported turning R1 every two hours as instructed by hospice. The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 did sustain pressure injuries during their stay at the facility, the investigation did not provide sufficient evidence to substantiate neglect/lack of care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 29-AS-20250131163051

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sandra Urena conducted a Case Management - Deficiencies visit due to deficiencies discovered during the investigation of complaint control number # 29-AS-20250131163051. The LPA met with the Administrator Ovsanna Khayalyan and explained the reason for the visit. During the Department’s investigation of complaint # 29-AS-20250131163051, the following deficiency was observed: The Department’s investigation revealed that R1 was admitted to the facility on 07/30/2024. The responsible party was listed as “self” and R1 signed the facility admission agreement. R1’s health declined, and on 10/30/2024, R1 was placed on the County of Los Angeles Public Guardian (LAPG) appointed Conservator’s caseload. On 11/14/2024 during a visit to the facility, the LAPG informed the administrator that R1 was under the LAPG and that they were R1’s conservator. On 11/30/2024, R1 was placed on Sunshine Care Hospice. The LAPG was not notified until 01/30/2025. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(a)(3) · Plan of correction due date: Jul 11, 2025

87633(a)(3) Hospice Care of Terminally Ill Residents (a)The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon …(3) Hospice agency services are contracted for by each terminally ill resident or prospective resident individually, or the resident’s or prospective resident's Health Care Surrogate Decision Maker if the resident or prospective resident is incapacitated, not by the licensee on behalf of a resident or prospective resident. These hospice agency services must be provided by a hospice agency both licensed by the state and certified by the federal Medicare program. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Licensee did not notify R1’s conservator (LAPG) that R1 was placed on hospice, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: The licensee will review regulations and will submit letter of acknowledgment to LPA Urena via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The Licensee Ovsanna Khayalyan arrived at the facility shortly thereafter. The LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The LPA observed common area to be clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and purchased on 05/; fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallways and passages. All exits have functioning auditory devices and were operational at the time of the visit. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 107.9-degree Fahrenheit. Medications are located in a locked kitchen cabinet. BEDROOMS: The facility is a single-story residential home with three (3) bedrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C… RESTROOMS: Restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid mats. Hot water= 105.6-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. There is a washer and dryer located in the staff's restroom. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the staff restroom. The first aid kit observed in the staff restroom. OUTDOOR SPACE: The patio has patio furniture and patio umbrella to provide shade for residents’ use. There is a gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. There are no bodies of water on the premises. RECORDS: Records review began at 12:27 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. All files were in order. MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster -Certificate Of Liability No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 20, 2025

Allegation investigated: Staff speak inappropriately towards a resident. Staff mishandle a resident's medication. Resident was physically abused while in care. Staff are denying a resident access to food.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to deliver the findings for the allegations listed above. The LPA was greeted by staff, and called the Administrator.The LPA explained the reason for the visit to the Administrator Ovsanna Khayalyan and read the report over on the phone. The Administrator allowed the facility staff to sign on the report. On 04/17/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an initial ten-day visit to investigate the allegations listed above. The LPA met with the Administrator Ovsanna Khayalyan and explained the reason for the visit. LPA Urena and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. No concerns were observed at this time. The LPA interviewed the Administrator, residents and staff from 10:05 a.m. to 01:25 p.m. Requested records pertinent to the investigation. Further investigation is needed at this time.Continues LIC 9099C... Unsubstantiated Pg. 2 Staff speak inappropriately towards a resident. On the allegation that staff speak inappropriately towards resident, it is the concern of the reporting party (RP) that staff speak disrespectfully to residents in care. To investigate the allegation, LPA Urena conducted residents’ interviews. The LPA interviewed four (4) out of five (5) residents, one resident was unavailable for the interview. The interviews revealed that staff are never disrespectful, nor do they raise their voices. One resident stated that they thought they heard staff use loud voice but was not sure. Staff denied being disrespectful to residents in care. Based on the information obtained through interviews, the residents stated that staff speaks to them respectfully. Therefore, the allegation is deemed Unsubstituted at this time. Staff mishandle a resident's medication. On the allegation that staff mishandle a resident's medication; it is the concern of the reporting party that staff are not dispensing the medications to residents as prescribed (timely). To investigate the allegation, LPA Urena conducted residents’ and staff interviews and conducted a random medication audit of residents’ medications compared to the Centrally Stored Medication and Destruction Record (LIC622). The interview with residents revealed that they receive their medications on time and according to their doctor’s orders. The medication audit revealed that the medications selected for audit were accurately dispensed, per physician’s orders. Based on the information obtained through interviews, and medication audit, the residents are receiving their medications according to the physician’s orders. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on LIC 9099C pg. 3 Pg. 3 Resident was physically abused while in care. On the allegation that a resident was physically abused while in care; it is the concern of the reporting party that the RP witnessed staff physically abusing an elderly resident. The reporting party did not specify how the physical abuse was being perpetrated, and neither identified the elderly resident. To investigate the allegation, LPA Urena conducted residents’ interviews and residents’ representative’s interviews. The interviews revealed that staff have not abused residents physically nor in any other way. Residents are happy with the care they receive from the staff and the Administrator. The LPA interviewed the RP and the RP denied witnessing any physical abuse. Staff denied being physically abusive towards residents in care. The Administrator stated that no concerns or reports of abuse have been brought up by residents or their representatives. Based on the information obtained through interviews, residents reported that they are happy at the facility and denied any staff was physically abusing them. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are denying a resident access to food. On the allegation that staff are denying a resident access to food, it is the concern of the reporting party (RP) that staff are not allowing residents access to the kitchen until after 8:00 a.m. To investigate the allegation, LPA Urena conducted residents’ and staff interviews. The residents’ interviews revealed that they receive three meals a day plus they are offered several snacks throughout the day. If they get hungry, they can ask the staff for food. They are never denied food. The staff interviews revealed that they serve breakfast between 8:00 a.m. and 8:30 a.m. lunch between 12:30 p.m. and 1:00 p.m., snacks in between and dinner at around 5:00 p.m. The LPA interviewed the RP, and the RP recognized that the staff are trying to take care of R1’s health, and that they do not actually deny the food, and is more about the food being consumed late at night. Based on the information obtained through interviews, RP denied being hungry or not having access to food or getting enough food during meals. Therefore, the allegation is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 29-AS-20250414113412

Allegation investigated: Facility staff did not seek timely medical attention for resident. Facility staff did not arrange transportation for resident in care.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegations listed above. The LPA arrived at the facility and was greeted by staff. Staff contacted the Administrator via telephone. The Administrator Ovsanna Khayalyan arrived at 10:45 a.m. LPA Urena 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. LPA Urena requested records pertinent to the investigation at 10:50 a.m. and interviewed the resident, Administrator, and staff between 10:25 a.m. to 12:50 p.m. LPA Urena was unable to reach the reporting party (RP), but was able to speak with R1's case worker (CW) from 1:05 p.m. to 1:46 p.m. CW stated that the RP was a temporary employee and is no longer working for the company. Continues on LIC 9099C... Unsubstantiated Facility staff did not seek timely medical attention for resident. On the allegation that Facility staff did not seek timely medical attention for resident, it is the concern of the reporting party (RP) that the resident (R1) was experiencing chest pains and the facility staff failed to observe the changes in condition and did not seek timely medical attention for R1. The interview with R1 revealed that on 02/18/2025 probably after 2:00 p.m. they were feeling fine when they decided to go on a walk in the community, however after some time during the walk they started to feel weak and knowing that the hospital was nearby, they decided to walk themselves to the hospital. At the hospital they were admitted after being diagnosed with pneumonia. R1 stated that the facility Administrator called them and it was at this time that R1 informed the Administrator that they were admitted to the hospital. Interviews with the Administrator and the staff revealed that they did not notice any changes in R1's condition on 02/18/2025. R1 had lunch that day and decided to go on a walk sometime after lunch. R1 had been admitted in the facility two days prior to the incident, and R1 was in good spirits. Based on the information obtained through interviews, the allegation that facility staff did not seek timely medical attention for resident, is deemed Unsubstantiated at this time. Facility staff did not arrange transportation for resident in care. On the allegation that the Facility staff did not arrange transportation for resident in care, it is the concern of the RP that R1 was denied transportation to the hospital when they were not feeling well, and consequently R1 had to walk to the hospital. The interview with R1 revealed that on 02/18/2025, at around 2:00 p.m., they told the facility staff, “they were going on a walk”. R1 went stated that during the walk they felt weak. R1 stated that they know the area well and decided to walk to the nearby hospital, which is about 10 minutes of walking distance from the facility. R1 stated that they were confused, and ‘out of it’, when hospital staff interviewed them. R1 denied the statement provided by the RP in the complaint report. The interview with the Administrator revealed that R1 stated that they wanted to go on a walk. The Administrator stated that because R1 had been admitted to the facility only two days before, they were concerned about the walk, however R1 insisted on the walk. Furthermore, the Administrator stated that they told R1 to take the facility’s business card in case they got disoriented or lost and didn’t know how to get back. Per the Administrator R1 has a personal cell phone. The Administrator stated that they called R1 after 15 minutes but R1 did not answer the phone. After an hour passed, the Administrator called R1 again, at this time R1 answered the phone and R1 stated they were admitted to the hospital. The Administrator then informed R1’s emergency contacts that R1 was admitted to the hospital. Continues on pg. 3 Page 3. The LPA spoke with a R1’s case worker (CW) assigned to follow up with R1 for a month after placement at the facility. The CW stated that case notes dated 02/21/2025 indicate that R1 stated that they are happy residing at this facility. Based on the information obtained through record review and interviews, the allegation that facility staff did not arrange transportation for resident in care, is deemed Unsubstantiated at this time. No citations were issued at this time. Exit interview was conducted and a copy of the report was issued. Facility staff yells at resident in care. On the allegation that the facility staff yells at residents, the interview with the resident (R1), revealed that this allegation is based on different facility where they were previously residing, and that it was a mistake, wrong facility. Therefore, the allegation is deemed to be Unfounded, at this time. Facility staff forces to eat. On the allegation that the facility staff forces residents to eat, the interview with the resident (R1), revealed that this allegation is based on different facility where they were previously residing, and that it was a mistake, wrong facility. Therefore, the allegation is deemed to be Unfounded, at this time. Facility staff forces to take medication. On the allegation that the facility staff forces residents to take medication,the interview with the resident (R1), revealed that this allegation is based on different facility where they were previously residing, and that it was a mistake, wrong facility. Therefore, the allegation is deemed to be Unfounded, at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 29-AS-20250219161649

Allegation investigated: Staff are not ensuring resident's hearing aid is replaced. Staff are not providing resident with mail. Staff are not meeting resident's needs.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 11:00 a.m., the LPA met with staff and explained the reason for the visit. At 11:27 a.m., the Licensee, Ovsanna Khayalyan arrived at the facility. During the initial visit conducted on 9/14/2023 between 2:15 p.m. and 3:35 p.m., LPA Sandra Urena conducted a physical plant tour and conducted an interview with the Licensee. During the initial visit, the LPA also obtained copies of pertinent documents. During today’s visit, at 11:30 a.m., LPA Peraldi conducted an interview with the Licensee. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Staff are not ensuring resident's hearing aid is replaced. It was alleged that Resident #1’s (R1’s) hearing aid was not operable, and the Licensee did not assist with replacing the hearing aid. The Licensee stated that she made an appointment for R1 to a hearing center, and the appointment was set for 08/07/2023, but R1 had left to a Skilled Nursing Facility (SNF) in July 2023. R1 did not come back to the facility until 09/02/2023. The Licensee provided the LPA with the appointment card for R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff are not providing resident with mail. It was alleged that the Licensee would not provide R1 with R1’s mail. The Licensee stated that she would give R1’s mail to R1 and that she would keep R1’s mail at the front of the facility for R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff are not meeting resident's needs. It was alleged that R1 was not taken care of properly as R1 developed wounds while in care. Per record review, R1 was admitted to the facility on 05/06/2023 and left around July 2023 and was readmitted on 09/02/2023. R1’s primary diagnosis upon admission per physician report dated 5/4/2023 is listed as severe sepsis, acute chronic renal failure, acute chronic respiratory failure, atrial fibrillation (afib), bilateral pneumonia, and chronic obstructive pulmonary disease (COPD). R1 also had Mild Cognitive Impairment (MCI). Per physician report dated 5/4/2023, R1 was not on hospice services. R1 did start receiving hospice services on 05/23/2023. Medical records for R1’s hospitalization on 6/27/2023 did not note any pressure ulcers. R1 was at a Skilled Nursing Facility (SNF) from around July 2023 and returned back to the facility on 09/02/2023. The Licensee stated that from the SNF, R1 developed the pressure ulcers. The Licensee stated that she readmitted R1 since R1 would be getting wound care with hospice. Physician report dated on 9/2/2023, noted R1 had pressure ulcers stage 3 and stage 4 on ankles. R1’s physician report dated 9/2/2023, stated that R1 was receiving hospice services. R1’s medical record dated 8/30/2023 stated that R1 had a pressure ulcer on left ankle, stage 4. The LPA called the SNF to confirm that R1 was admitted between July 2023 and September 2023. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 29-AS-20230907155842

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The Licensee Ovsanna Khayalyan arrived at the facility shortly thereafter. The LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The LPA observed common area to be clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and purchased on 01/19/2024; fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallways and passages. All exits have functioning auditory devices and were operational at the time of the visit. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 107.9-degree Fahrenheit. Medications are located in a locked kitchen cabinet. BEDROOMS: The facility is a single-story residential home with three (3) bedrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C… RESTROOMS: Restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid mats. At 12:15 p.m., hot water 105.6-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. There is a washer and dryer located in the staff's restroom. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the staff restroom. The first aid kit observed in the staff restroom. OUTDOOR SPACE: The patio has patio furniture and patio umbrella to provide shade for residents’ use. There is a gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. There are no bodies of water on the premises. RECORDS: Records review began at 12:37 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. All files were in order. MEDICATIONS: Medications review began at 1:50 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 18, 2024