Silver Light Care

Type of visit: Case Management - Other

Licensing Program Analyst Trevor Byrne created this report to follow up on a substantiated allegation of a complaint investigation. The facility closed on August 1, 2025. The LPA delivered the report via e-mail, first class mail, and certified mail. On November 7, 2025, the Department concluded a complaint investigation regarding the following allegation: Due to neglect, resident sustained pressure injuries while in care and Due to neglect, resident had to have a partial foot amputation. The licensee was cited for California Code of Regulations (CCR) 87464 (f)(1) Basic Services and CCR 87405(d)(7)(1) Administrator Qualifications. At the time of the complaint visit on November 7, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). CONTINUED ON LIC 809C. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision and delayed seeking medical attention for a resident (R1), which resulted in the hospitalization for right foot osteomyelitis, cellulitis, and sepsis that lead to a right foot partial 5th ray resection. Today, April 14, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines Serious Bodily Injury in the amount of $10,000. However, since an immediate civil penalty of $500 was issued on November 7, 2025, the amount of the civil penalty issued today will be $9,500. A copy of the report was issued via e-mail, first class mail, and certified mail. Appeal rights provided with a copy of the report. Facility representative signature is requested, acknowledging receipt of the report and appeal rights, found on page two of the LIC 421D.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Case Management - Other

Licensing Program Analyst Trevor Byrne created this report to follow up on a substantiated allegation of a complaint investigation. The facility closed on August 1, 2025. The LPA delivered the report via e-mail, first class mail, and certified mail. On January 7, 2026, the Department concluded a complaint investigation regarding the following allegation: Staff physically abused residents and staff verbally abused residents. The licensee was cited for California Code of Regulations (CCR) 87468.1(a)(3) Additional Personal Rights of Residents in Privately Operated Facilities and CCR 87468.1(a)(1) Additional Personal Rights of Residents in Privately Operated Facilities. At the time of the complaint visit on January 7, 2026, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. The Welfare and Institutions Code Section 15610.63 for physical abuse means any of the following: (a) Assault, as defined in Section 240 of the Penal Code. This is evidenced by staff (S1) striking a resident (R1) with a closed fist five (5) times on their left temple resulting in discoloration on the left side of R1’s face. Additional interviews with other residents (R2 and R6), revealed that S1 had also struck them in the past. CONTINUED ON LIC 809C. Today, April 14, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as physical abuse in the amount of $10,000. However, since an immediate civil penalty of $500 was issued on January 7, 2026, the amount of the civil penalty issued today will be $9,500. A copy of the report was issued via e-mail, first class mail, and certified mail. Appeal rights provided with a copy of the report. Facility representative signature is requested, acknowledging receipt of the report and appeal rights, found on page two of the LIC 421D.the state’s words, verbatim · CDSS document, Apr 14, 2026

Allegation investigated: Staff physically abused residents Staff verbally abused residents

Licensing Program Analyst (LPA) Trevor Byrne created this report to deliver findings for the above listed allegations. The facility Silver Light Care 195850239 was closed effective 08/01/2025 due to a Temporary Suspension Order (TSO) issued on 08/01/2025. LPA attempted to contact the former licensee via telephone call on 01/07/2026 between 01:35 PM and 01:37 PM to review this report. LPA was unable to make contact with the former licensee at either phone number available. A copy of this report will be emailed to the former licensee and mailed to the former licensee’s mailing address for signature. Continued on LIC 9099C. Substantiated On 08/04/2025 the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint alleging that Staff #1 (S1) physically and verbally abused Resident #1 (R1), and Resident #2 (R2). The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and was assigned to Investigator Veronica Padilla. During the initial complaint visit on 08/04/2025, LPAs Byrne and Urena conducted a physical plant tour and interviewed four (4) residents; Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4) at Silver Light Care 195850665 which was being operated by a Temporary Manager due to the TSO issued on 08/01/2025. During the inspection, LPA Byrne observed discoloration on the left side of R1’s face near their left eye and obtained photographs. On 08/26/2025, between approximately 09:00 AM and 09:15 AM IB Investigator Padilla contacted Los Angeles Police Department (LAPD) Detective and reviewed LAPD police reports. On 09/03/2025, at approximately 09:30 AM Investigator Padilla interviewed the temporary manager (TM) of Silver Light Care 195850665. On 09/03/2025, at approximately 09:55 AM Investigator Padilla obtained facility/resident documents pertaining to the investigation. On 09/04/2025, at approximately 08:40 AM Investigator Padilla interviewed R2. On 09/04/2025, at approximately 09:30 AM Investigator Padilla interviewed R1. On 09/25/2025, at 11:00 AM Investigator Padilla and Investigator Hector attempted to interview Staff #2 (S2). On 09/25/2025, at 12:22 PM Investigator Padilla and Investigator Hector attempted to interview S1 and the former Administrator of Silver Light Care 195850239 (ADM). On 09/26/2025, at approximately 12:20 AM Investigator Padilla interviewed Resident #3 (R3). On 10/15/2025, at approximately 10:50 AM Investigator Padilla and Investigator Hector received an email from the attorney representing S1, S2, ADM, and Licensee Representative (LR) informing the Investigators that their clients are unwilling to provide a statement. On 11/05/2025, at approximately 10:15 AM Investigator Padilla interviewed Resident #4 (R4). On 11/14/2025, at 08:20 AM Investigator Padilla contacted LAPD Detective. On 12/15/2025, at 09:50 AM Investigator Padilla contacted the Long-Term Care Ombudsman (LTCO). Continued on LIC 9099C. The allegation of “Staff physically abused residents” alleges that S1 struck R1 on their face with a closed fist five (5) times on 07/31/2025 and S1 struck R2 with closed and open hands several times in the past. The additional allegation of “Staff verbally abused residents” alleges that S1 engaged in a verbal altercation with R1 over medication refusal and had yelled at facility residents previously. The interviews with R1 revealed that on 07/31/2025 S1 approached R1 and attempted to administer medications. R1 stated that they asked S1 what the medications were and S1 attempted to force the medications into R1’s mouth. When R1 refused the medications R1 stated that S1 struck them in the face with a closed fist five (5) times on their left temple. Interviews with R2 revealed that S1 had struck R2 with both closed and open hands on the head and face an unknown number of times in the past. Additionally, R2 stated that they observed S1 striking R1 on 07/31/2025. Interviews with R3 revealed that R3 had overheard the confrontation between S1 and R1 on the night of 07/31/2025. R3 reported hearing a verbal altercation between S1 and R1 over the administration of medications followed by the sounds of what seemed to be R1’s head hitting the wall followed by the sounds of R1 being struck by S1. Additionally, R3 reported that S1 had been verbally abusive with a former facility Resident #5 (R5). R3 stated that they did not reveal the abuse to LPAs or LTCO previously due to intimidation by S1. Investigator Hector interviewed Resident #6 (R6) as part of another complaint investigation for Silver Light Care 195850239. During this interview R6 reported that on 06/16/2025 S1 became upset with R6 and punched R6 on the right side of their face. R6 reported that S1 then proceeded to put their hands around R6’s neck and applied pressure to choke them. R6 stated that S1 released their grip after a few seconds and broke contact with R6. In a previous investigation conducted by CCLD IB Investigator Olivia Spindola, a physical abuse allegation against S1 was Substantiated for S1 hitting a resident at another facility where S1 worked. Investigator Padilla attempted to interview S1, S2, ADM, and LR but was advised by their attorney that they did not wish to provide a statement regarding these allegations. Based on the information obtained during interviews and by observation there is sufficient evidence to support the allegations of “Staff physically abused residents” and “Staff verbally abused residents.” Therefore, the allegations are deemed Substantiated at this time. The following deficiencies were cited, and a $500 immediate civil penalty is being assessed. (refer to LIC 9099D). A copy of this report and appeal rights will be emailed and mailed to the former licensee SILVER LIGHT CARE, INC., for signature. Additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 29-AS-20250804115415

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 7, 2026

87468.1 Personal Rights of Residents... (a) Residents...shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff... This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above as S1 verbally abused residents which posed an immediate personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 7, 2026

87468.1 Personal Rights of Residents... (a) Residents...shall have all of the following personal rights: (3) To be free from punishment...abuse, or other actions of a punitive nature... This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above as S1 physically abused residents and left R1 with visible discoloration on the left side of R1's face which posed an immediate health, safety, and personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 7, 2026

87465 Incidental Medical and Dental Care (a)... provide for assistance in obtaining such care, by compliance with... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as S1 forcefully administered medications ro R1 which posed an immediate personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne created this Case Management-Deficiencies report to address an incident that occurred at Silver Light Care 195850665 on 08/04/2025 at approximately 09:30 PM. The facility Silver Light Care 195850239 was closed effective 08/01/2025 due to a Temporary Suspension Order (TSO) issued on 08/01/2025. LPA attempted to contact the former licensee via telephone call on 01/07/2026 between 01:35 PM and 01:37 PM to review this report. LPA was unable to make contact with the former licensee at either phone number available. A copy of this report will be emailed to the former licensee and mailed to the former licensee’s mailing address for signature. On 08/04/2025 at 10:45 PM Community Care Licensing Division (CCLD) received a report from the Temporary Manager (TM) of Silver Light Care 195850665. TM informed CCLD that on 08/04/2025 former Administrator of Silver Light Care 195850239, Elba Khachatryan, arrived at the facility unannounced at approximately 9:30 PM and forcefully entered the facility. TM reported the following events. The former Administrator claimed they had instructions from Resident #1 (R1)’s and Resident #2 (R2)’s Power of Attorney (POAs) to remove them from the facility. However, the former Administrator was unable to make contact with the POAs via telephone for confirmation. The Former Administrator entered Resident #3 (R3)’s bedroom and demanded payment from R3 for rent for the month of August. R3 declined to pay the Former Administrator who left R3’s room and then entered R1’s bedroom. The Former Administrator stated, “you’re coming with me. Your family is waiting for you” to R1. Continued on LIC 809C. Continued from LIC 809. The Former Administrator then grabbed R1 by the hand and attempted to remove R1 from the facility despite R1’s visible confusion and fatigue. The Former Administrator then entered R2’s bedroom and physically lifted R2 off of the bed from their elbow. The former Administrator then forced shoes into R2’s hands and pulled R1 and R2 towards the facility entrance in an attempt to escort the residents out of the home. While the former Administrator attempted to usher R1 and R2 down the front steps of the facility R2 appeared unsteady and nearly fell. Facility staff intervened and assisted R2 to a seated position and then assisted R1 to a seated position for the safety of the residents. TM reported that law enforcement was contacted and responded to the home. Law enforcement attempted to contact the families of the residents but were unable to make contact. TM stated that law enforcement instructed the former Administrator that they would not be permitted to remove any residents that evening and that any transfer must occur during appropriate hours with verified family consent. R3 also reported receiving a text message approximately 30 minutes after the former Administrator left their room from Staff #1 (S1) requesting payment. On 08/05/2025 at 07:42 AM CCLD received a second report from TM of Silver Light Care 195850665. TM informed CCLD that on 08/05/2025 at 12:30 AM the former Administrator returned to the facility in another attempt to remove R3 from the facility. Facility staff immediately contacted law enforcement who arrived on scene. Facility staff and the former Administrator spoke with the responding officer who did not permit the former Administrator to remove any residents. Law enforcement instructed the former Administrator to leave the premises and the former Administrator left at approximately 01:00 AM. On 08/05/2023 R3 continued to receive phone calls and text messages from the former Administrator and S1 threatening to involve R3 in a lawsuit and to send them to collections for not paying August rent. R3 reported concerns and distress to the facility staff over the ongoing attempts to extract payment through threats and harassment by S1 and the former Administrator. On 08/06/2025, during a Case Management visit, R3 shared with LPA Bryne and LPM Lopez a text message and voicemail message from the former Administrator and S1 requesting rent for the month of August. During another CCLD investigation at Silver Light Care 195850239, Investigator Padilla attempted to interview the former Administrator and S1, but on 10/15/2025 was advised by their attorney that they did not wish to provide a statement therefore no interviews were attempted to be obtained for this investigation. Continued on LIC 809C. Continued from LIC 809C. The actions of the Administrator and S1 on the evening of 08/04/2025 and on 08/05/2025 were inimical to the health, morals, welfare, and safety of the residents in care and posed immediate risks to the personal rights of the residents in care. The following deficiencies were cited. (refer to LIC 9099D). A copy of this report and appeal rights will be emailed and mailed to the former licensee SILVER LIGHT CARE, INC., for signature.the state’s words, verbatim · CDSS document, Jan 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 7, 2026

87468.1 Personal Rights of Residents... (a) Residents...shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as the Administrator created an unsafe environment for the facility residents on 08/04/2025 by attempting to remove residents from the facility which posed an immediate safety and personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(3) · Plan of correction due date: Jan 7, 2026

87468.1 Personal Rights of Residents... (a) Residents...shall have all of the following personal rights: (3) To be free from...intimidation... or other actions of a punitive nature... This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above as the Administrator and S1 harassed and attempted to intimidate R3 into issuing payment to them which posed an immediate personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87408(a)(6) · Plan of correction due date: Jan 7, 2026

87408...Revocation of a Certificate (a) The Department may...revoke any administrator certificate... (6) The certificate holder engaged in conduct which is inimical to the... welfare, or safety of...an individual in...the facility... This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above as the Administrator's actions on 08/04/2025 were inimical to the welfare and safety of the residents in care which posed an immediate safety and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

Allegation investigated: Due to neglect, resident sustained pressure injuries while in care. Due to neglect, resident had to have a partial foot amputation

Licensing Program Analyst (LPA) Trevor Byrne created this report to deliver findings for the above listed allegations. The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. LPA attempted to contact the former licensee via telephone call on 11/07/2025 at 10:40 AM and 10:47 AM to deliver findings. Both telephone numbers available were disconnected/no longer belonged to the licensee. A copy of this report will be emailed to the former licensee and mailed to the former licensee’s mailing address for signature. On 08/05/2025 the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint alleging that due to neglect, resident #1 (R1) sustained pressure injuries while in care and due to neglect, R1 had to have a partial foot amputation. The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and was assigned to Investigator Edward Hector. During the initial complaint visit on 08/06/2025 LPAs Byrne and Urena conducted a physical plant tour and interviewed the temporary manager (TM) of Silver Light Care 195850665 and interviewed four (4) residents. Continued on LIC 9099C. Substantiated On 08/15/2025, at 12:59 PM IB Investigator Hector interviewed Witness #1 (W1). On 08/21/2025, at 01:23 PM Investigator Hector interviewed R1. On 08/27/2025, at 12:59 PM Investigator subpoenaed documents from the hospital that treated R1. On 08/28/2025, obtained the Los Angeles Police Department (LAPD)’s Investigations reports. On 09/03/2025, at 08:26 AM IB received medical records from the hospital that treated R1. Between 09/09/2025 and 09/23/2025, the Investigator corresponded with LAPD Detective. On 09/23/2025, at 12:16 PM the Investigator contacted Wise & Healthy Aging, Long-Term Care Ombudsman Program (LTCO). On 09/25/2025, at 11:00 AM the Investigator attempted to interview Staff #1 (S1) at their home but was unavailable, although contact was made with Individual #1 (I1). On 09/25/2025, at 12:22 PM the Investigator attempted to contact Staff #2 (S2) at their home but was unavailable. On 09/25/2025, at 12:44 PM, the Investigator received a message from I1 but later advised S1 was no longer available for interview. On 10/08/2025, IB mailed certified U.S. Postal Service letters to S1 and S2 requesting an opportunity to get their statements. On 10/15/2025, the Investigator received a phone call from an attorney representing S1 and S2 stating both S1 and S2 declined to provide a statement. The allegation of “Due to neglect, resident sustained pressure injuries while in care.” alleges that due to neglect by facility staff R1 sustained pressure injuries to the foot and heel area. The additional allegation of “Due to neglect, resident had to have a partial foot amputation” alleges that due to neglect by facility staff R1 sustained a condition that resulted in a partial amputation of R1’s foot. The interview with W1 revealed that after the TSO for Silver Light Care 195850239 was issued the temporary management company assumed operations of the facility under Silver Light Care 195850665. After assuming operations of the facility staff employed by TM conducted assessments of the residents that remained at the facility. W1 reported observing R1 with Stage 3 and Stage 4 wounds. W1 advised that R1 was only at the facility for one (1) day while the Temporary Management company was assigned to the facility before being transferred to the hospital for treatment on 08/02/2025. Continued on LIC 9099C. Medical record review revealed R1 had a non-healing ulcer on his right foot that included sepsis, osteomyelitis, and right foot cellulitis. Further review of the medical records revealed that R1 had a left heel pressure injury, left foot deep tissue injury, and a right foot non-healing ulcer to his 4th and 5th metacarpal with X-rays of the right foot revealing that R1 had bone erosion to the lateral 5th metatarsal head. Records review further revealed that on 08/03/2025, R1 participated in a surgical procedure “right foot partial 5th ray resection due to osteomyelitis” the fifth toe and at least a portion of its associated metatarsal bone (the fifth ray) were removed because of an infection in the bone called osteomyelitis. Record review revealed no evidence to support that R1 had received any prior wound care from an appropriate skilled professional while under the care of the licensee. During the interview with R1 they stated that they first observed the wound on their foot seven (7) months ago and described the wound as a “hole inside their foot”. R1 stated that S1 observed the wound and “tried to wrap it up”. R1 reported that S2 came to the facility after a while and observed the injury. R1 reported that S2 stated that they were planning on calling the hospital but R1 denied ever going to the hospital for treatment of the wound. R1 denied a doctor, nurse, home health professional, or hospice representative coming to the facility to look at their injury. R1 confirmed that the only care the facility staff provided was to wrap their foot with bandage tape. R1 stated that the appearance of the injury got worse over time. R1 denied having any pain due to their lack of sensation in the lower extremities due to paraplegia. The investigator attempted to interview S1 and S2 but was advised by their attorney that they did not wish to provide a statement regarding these allegations. Based on the information obtained during interviews and record review there is sufficient evidence to support the allegations of “Due to neglect, resident sustained pressure injuries while in care” and “Due to neglect, resident had to have a partial foot amputation.” Therefore, the allegations are deemed Substantiated at this time. The following deficiencies were cited (refer to LIC 9099D). A copy of this report and appeal rights will be emailed and mailed to the former licensee SILVER LIGHT CARE, INC., for signature. A $500 immediate civil penalty is also being assessed today. Additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 29-AS-20250805085307

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 7, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to provide care and supervision resulting in R1 sustaining pressure injuries and a partial foot amputation which is an immediate health and safety risk to R1 in care.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(7)(1) · Plan of correction due date: Nov 7, 2025

87405 Administrator - Qualifications... (d) The administrator shall have the qualifications specified.... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure R1 received proper care which resulted in R1 sustaining pressure injuries and a partial amputation which is an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 7, 2025

87211 Reporting Requirements (a) Each licensee shall furnish...: (1) A written report shall be submitted to... licensing...within seven days of... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record review, the licensee failed to submit an incident report to CCL regarding R1 sustaining pressure injuries in a timely manner which is an immediate health and safety risk to R1 in care.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: The facility Silver Light Care 195850239 was closed effective August 1, 2025 due to a Temporary Suspension Order (TSO) issued on August 1, 2025. There is no POC for this citation.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Trevor Bryne, and Sandra Urena, along with Licensing Program Managers (LPMs) KaSandra Lopez, and Ulysses Coronel, and Regional Manager (RM) Benita Yates conducted an unannounced case management visit at this facility. The purpose of the visit is to issue a Temporary Suspension Order (TSO). The TSO effective date is the close of business hour today. RM, LPMs, and LPAs met with facility staff Tatyana Sevostyanova. Facility staff contacted the facility Administrator Elba Khachatryan via telephone call. The Administrator did not arrive to the facility during today's visit, although RM Yates spoke with Administrator Elba Khachatryan during the inspection. During today’s visit Elba Khachatryan was located at another assisted living facility, Rossmoyne Hills. Elba Khachatryan was served the TSO for Silver Light Care, INC. at Rossmoyne Hills. A copy of the TSO was left at the facility. A Temporary Manager is being implemented to allow placement agencies sufficient time to assist with placement of the six (6) residents. The Temporary Manager arrived during the visit, to take over operation of the facility. During today's site visit, the RM also left copies of the "Order to Individual for Immediate Exclusion from All Facilities" for Edgar Khachatryan and Knarik Panosyan. It was determined by the Department that a complaint of conduct inimical was substantiated against Edgar Khachatryan and Knarik Panosyan, thus, necessitating the Order for Immediate Exclusion from the facility. Today, RM left copies of the Immediate Exclusion Orders for Silver Light Care regarding Edgar Khachatryan and Knarik Panosyan, along with a copy of the “Order to Individual for Immediate Exclusion from All Facilities" at the facility. Continued on LIC 809C. The Order regarding Individual Exclusion indicates that Edgar Khachatryan and Knarik Panosyan are not allowed to have contact with clients or to be present at any facility licensed by the California Department of Social Services. During today's visit the facility license for Silver Light Care INC. was removed from the facility. A copy of the letters will also be mailed via regular mail and via certified mail. No individual representing the facility was available to sign this report. Appeal rights and copy of this report were issued and left at the facility.the state’s words, verbatim · CDSS document, Aug 1, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 01:46 PM to conduct an unannounced Case Management – Other inspection at the facility today. LPA met with facility staff Tatyana Sevostyanova. Facility staff contacted the facility Administrator Elba Khachatryan via telephone call. The facility Administrator was unable to come to the facility at the time of the investigation but has designated facility staff to sign this report on their behalf. Entrance interview conducted. During today’s visit LPA conducted a physical plant tour and interviewed six (6) of six (6) residents. No immediate health and safety concerns were observed. LPA observed the facility to be clean and supplied with sufficient amounts of food. All residents interviewed stated that they are fed well, staff are doing a good job, and medications are given appropriately. No residents interviewed had concerns with the facility at the time of the inspection. LPA briefly discussed the inspection authority of the licensing agency with the Administrator during today’s visit. No deficiencies were observed during today’s inspection. This report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 31, 2025

Allegation investigated: Staff left resident in soiled diapers/clothes for an extended period of time. Staff put residents to bed early. Staff are not assisting residents at night. Resident was not provided with adequate food service.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint visit for the above allegations. LPA arrived to the facility at 01:27 PM and met with facility staff #2 (S2). LPA contacted the facility Administrator Elba Khachatryan via telephone call. The facility Administrator did not arrive to the facility during today’s visit and has designated S2 to sign this report on their behalf. Entrance interview conducted and the reason for the visit was explained. During today’s visit between 01:30 PM and 02:30 PM LPA conducted a physical plant tour, obtained copsies of documents, interviewed six (6) residents, one (1) staff, and delivered findings for the above allegation. Continued on LIC 9099C. Unsubstantiated The allegation of “Staff left resident in soiled diapers/clothes for an extended period of time.” alleges that resident #1 (R1) was left in soiled diapers overnight between the approximate hours of 07:00 PM and 07:00 AM. LPA interviewed R1 who stated that for five (5) nights during their stay at the facility they were not changed in the evening by staff. R1 confirmed that they never asked Staff #1 (S1) for assistance with changing at night due to being instructed by the Administrator not to bother staff after 7:00 PM. LPA interviewed S1 who confirmed that R1 never asked for assistance with being changed in the evening during their stay at the facility. LPA interviewed the Administrator who denied telling R1 that they were not allowed to ask for assistance from the caregiver at night. The Administrator provided LPA with proof of a bedside commode that was delivered to the facility on 06/04/2025 for R1’s use. The Administrator stated that one (1) commode was placed in R1’s room near their bedside and one (1) was placed in the facility bathroom but R1 refused to utilize either commode. Interviews with the Administrator and S1 revealed that they are aware that staff are required to assist residents at night. The interview with Resident #3 (R3) revealed that in the past they have asked S1 for assistance with changing at night and S1 has assisted them. No current residents interviewed had concerns about being left in soiled garments for extended periods of time. Based on the information obtained during interviews and physical plant tour although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff left resident in soiled diapers/clothes for an extended period of time” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff put residents to bed early.” alleges that facility staff require residents to remain in bed after approximately 7:00 PM each day. Interviews with the Administrator, S1, R2, R3, and R4 revealed that there is no specific time residents are required to be in bed, but residents are expected to keep noise at a minimum in the evening to be respectful to the other residents of the facility. The Administrator informed LPA that R1 would utilize their personal laptop and speaker to conduct personal conversations until approximately 11:00 PM which caused disturbances to the other residents. LPA reviewed the facility house rules and observed the following “TV, radio, and all noise must be turned down after 10:00 PM.” LPA did not observe house rules relating to a curfew or enforced bedtime for residents. Based on the information obtained during interviews and physical plant tour although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff put residents to bed early.” Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C. The allegation of “Staff are not assisting residents at night.” alleges that facility staff did not assist R1 with their care needs between the approximate hours of 07:00 PM and 07:00 AM. Interviews with the facility Administrator and S1 revealed that S1 is the primary caregiver and is present at the facility twenty four (24) hours a day for six (6) days of the week with S2 covering for the seventh (7) day of the week. Interviews with S1 and the Administrator confirmed that S1 knows that they are required to provide care to the residents during the evening hours. S1 stated that if requested at night they assist residents in caring for their needs. Interviews with resident #2 (R2), resident #3 (R3), and resident #4 (R4) did not reveal concerns with asking staff for assistance with their needs during the night. LPA observed S1’s bed to be located adjacent to the kitchen in a central area of the facility. LPA interviewed R1 who stated that they never asked S1 for assistance at night due to being instructed not to by the facility Administrator. In an interview with S1 they confirmed that R1 never requested assistance from them at night. The facility Administrator denied telling R1 that they were not allowed to ask for assistance from the caregiver at night. Based on the information obtained during interviews although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff are not assisting residents at night.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Resident was not provided with adequate food service.” alleges that R1 was not fed for three days while they resided at the facility. LPA conducted a physical plant tour of the facility on 06/16/2025, 07/15/2025, and 07/30/2025 and observed the location to have sufficient amounts of perishable and non-perishable foods. LPA interviewed S1 who stated that in addition to providing care to the residents they cook three (3) meals a day for the residents of the facility. S1 denied R1 refusing food but stated that R1 would consume snacks that they had brought from outside of the facility rather than eating the meals that were provided. Interviews with R2 corroborated that R1 would prefer to consume the outside snacks over the food the facility provided. Additionally, R2 stated that R1 was served meals at the same time as the other residents in the facility. Interviews with R2, R3, and R4 did not reveal concerns about the quality, frequency, or quantity of meal service at the facility. The Administrator confirmed that the facility provides residents with three (3) meals a day and snacks are available between meals. Additionally, the Administrator provided LPA with photos of meals that are served to residents, the food served appeared to be of good quality and served in sufficient amounts. Based on the information obtained during interviews and physical plant tour although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Resident was not provided with adequate food service.” Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C. This report was read to the Administrator via telephone call. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 29-AS-20250611114359

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management – Deficiencies visit at the facility today. LPA arrived to the facility at 02:02 PM and met with facility staff Tatyana Sevostyanova. Facility staff contacted the facility Administrator Elba Khachatryan via telephone call. The facility Administrator arrived to the facility at approximately 02:30 PM. Entrance interview conducted and the reason for the visit was explained. During today’s visit between 02:05 PM and 03:15 PM LPA conducted a physical plant tour, conducted a file review for six (6) residents, interviewed two (2) residents and collected copies of resident documentation. During file review LPA observed resident #1’s (R1)’s physician report to be missing a signature from a licensed medical professional acting within their practice. LPA informed the Administrator who stated that the physician’s report came from a different nursing home and agreed to obtain a copy of the report with the licensed medical professional’s signature on the bottom of the sheet. LPA observed R1’s file to be missing a pre-admission appraisal. LPA informed the Administrator who stated that they did conduct an interview with R1 but they have not completed the paperwork yet. LPA informed the Administrator that facilities are responsible for documenting, in writing the findings of the pre-admission appraisal, and any reappraisal or assessment. The Administrator agreed to complete R1’s pre-admission appraisal and send a copy to LPA once completed. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505 · Plan of correction due date: Jul 29, 2025

87505 Documentation and Support Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-admission Appraisal, ... This requirement is not met as evidenced by: Based on interview and file review the licensee did not comply with the section cited above as R1's file was observed to be missing a documented pre-admission appraisal which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator agreed to complete documentation of the identified resident's pre-admission appraisal and send proof of this documentation no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Jul 29, 2025

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional ... This requirement is not met as evidenced by: Based on interview and file review the licensee did not comply with the section cited above as R1's file was observed to be missing a signature on their medical assessment which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator agreed to obtain a copy of R1's medical assessment with a signature no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:01 AM. LPA met with facility staff who contacted the facility Administrator Elba Khachatryan. The Administrator arrived to the facility at 10:25 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:15 AM the LPA, along with facility staff and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. At 10:20 AM LPA observed an un-secured cabinet located above the facility fridge to contain knives and other sharp objects. Administrator placed a locking device on the cabinet during the visit. LPA observed a fire extinguisher mounted on the wall to be purchased on 04/13/2024. At 10:24 AM LPA observed an unsecured under-sink cabinet in the kitchen to contain cleaning chemicals including glass cleaner and Clorox bleach wipes. The Administrator installed a locking device at the time of the visit. Continued on LIC 809C. COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained an infection control point and all required postings. The hallway was observed to contain a locked storage closet which contained extra care supplies and PPE supplies. The dining area was observed to contain a fireplace, it is appropriately screened and contains no tools. Additionally, the dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:46 PM and were functional at the time of the visit. BEDROOMS: There are three (3) bedrooms in the facility; all three (3) are dual occupancy resident rooms. LPA and facility Administrator toured all three (3) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contains a direct exit to the outdoors of the facility. BATHROOMS: There are two (2) bathrooms at the facility. Both are designated as shared/common resident bathrooms. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets. LPA observed one (1) shower grab bar located in the non-ambulatory resident bathroom to be improperly secured to the wall. LPA informed the Administrator who agreed to perform needed repairs to the grab bar. The water temperature was measured to be between 117.6 and 114.6 degrees Fahrenheit, which is in compliance with regulation. OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the backyard to contain a pool. It was appropriately fenced off and made inaccessible to clients in care. LPA observed all railings to be sturdy and appropriately secured. Continued on LIC 809C. GARAGE: LPA observed the garage to be un-locked and accessible to clients in care. LPA observed the garage to contain the facility’s washer and dryer, adequate emergency food and water supplies, and an extra refrigerator. At 10:51 AM LPA observed the garage to contain unsecured cleaning chemicals, laundry chemicals, and tools including a saw. LPA informed the Administrator of the unsecured items. The Administrator agreed to secure the items into a locked storage. LPA advised the Administrator that they were previously cited for a violation of CCR 87309(a) on 10/22/2024 and 03/01/2025. LPA advised Administrator that a civil penalty in the amount of $250 will be assessed on today's date (05/06/2025) due to a repeat violation of the same regulation within a 12-month period. RECORD REVIEW: Record review began at 11:05 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. Three (3) staff files were observed to contain incomplete LIC 501 forms and were missing information including the employee’s home address, educational background, past experience, including types of employment and former employers, type of position for which employed, termination date, and reasons for leaving. Additionally, LPA observed one (1) employee to be missing proof of a negative TB test. LPA informed the Administrator who agreed to have the identified employees fill in the missing information and agreed to obtain proof of a negative TB test for the identified employee. LPA observed staff #1 (S1) to be assisting in distributing resident medications at the time of the visit. LPA observed the training records for S1. LPA did not observe documentation of S1 completing medication assistance training. LPA informed the Administrator who stated that classes were given by a nurse. The Administrator was unable to provide LPA with proof of course completion at the time of the visit. Continued on LIC 809C. RECORD REVIEW CONTINUED: Six (6) resident files were reviewed. Three (3) resident files were observed to have their admission agreements missing the amounts charged for basic services. LPA informed the Administrator who amended the admission agreements with the correct amounts charged and obtained resident’s signatures confirming the correct amount during the visit. LPA observed one (1) resident's file to contain two (2) incident reports dated 01/22/2025 and 04/19/2025. LPA reviewed the facility's e-file and the LPA's in-box for proof of the submitted incident reports. LPA did not observe the incident reports in either location. LPA asked the Administrator if the reports were submitted to licensing. The Administrator stated that they believe they were but the Administrator was unable to provide proof of submittal at the time of the inspection. LPA reminded the Administrator that all incident reports must be submitted to licensing no later than seven (7) days following the incident. MEDICATION REVIEW: Medication review began at 01:14 PM. Medications for three (3) of six (6) residents were observed. LPA observed two (2) resident’s centrally stored medication and destruction record sheets (CSMDRs) to contain out of date information including prescription numbers and the dates the medications were started. Additionally, LPA observed one (1) resident medication to not be listed on the resident’s CSMDR. LPA informed the Administrator who agreed to update the identified resident’s CSMDRs with accurate medications and other required information. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/26/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. Continued on LIC 809C. INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. LPA interviewed one (1) staff member with the assistance of the Administrator acting as a translator. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 02:02 PM to conduct an unannounced Case Management – Other inspection at the facility today. LPA met with facility Administrator Elba Khachatryan the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour and interviewed five (5) of six (6) residents as one (1) resident asleep at the time of the inspection. No immediate health and safety concerns were observed. All residents interviewed stated that they are fed well, staff were present at the facility all week, and medications were given on time. No residents interviewed had concerns with the facility at the time of the inspection. CCLD had previously requested a copy of the facility's LIC 500 on 03/08/2025 LPA obtained a copy of the facility's LIC 500 from the facility Administrator. No deficiencies were observed during today’s inspection. LPA read this report in the presence of the Administrator. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 11, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Trevor Byrne and Long Term Care Ombudsman (LTCO) Ginger Perini arrived to the facility at 01:39 PM to conduct an unannounced Case Management – Other inspection at the facility today. LPA met with facility Administrator Elba Khachatryan the reason for the visit was explained. During today’s visit LPA and LTCO conducted a physical plant tour and interviewed four (4) of six (6) residents as one (1) resident asleep and one (1) resident refused interview at the time of the inspection. No immediate health and safety concerns were observed. All residents interviewed stated that they are fed well, staff were present at the facility all night, and medications were given. No residents interviewed had concerns with the facility at the time of the inspection. CCLD had previously requested a copy of the facility's LIC 500 on 03/01/2025, 03/02/2025 and 03/03/2025. LPA attempted to speak with the Administrator as they previously stated that they would provide a copy of the LIC 500 no later than end of day Monday 03/03/2025. The Administrator refused to speak with LPA and stated that all communications should be conducted through their attorney. LPA informed the Administrator that the Department has requested the facility’s LIC 500 on three (3) separate occasions. LPA informed the Administrator that the Department is requesting this document to confirm adequate staff coverage and to ensure there are staff present 24/7 at the facility. LPA informed the Administrator that failure to provide this document to the Department could affect their Administrator’s certificate. No deficiencies were observed during today’s inspection. LPA read this report in the presence of the Administrator. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 01:50 PM to conduct an unannounced Case Management – Other inspection at the facility today. LPA met with facility staff member Keyna Nkumbula (S1) who contacted the facility Administrator Elba Khachatryan via telephone call entrance interview conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour and interviewed five (5) of six (6) residents as one (1) resident was out of the facility at the time of the inspection. No immediate health and safety concerns were observed. All residents interviewed stated that they are fed well, staff were present at the facility all night, and medications were given. No residents interviewed had concerns with the facility at the time of the inspection. CCLD had previously requested a copy of the facility's LIC 500 on 03/01/2025 and 03/02/2025. On 03/02/2025 the Administrator stated that they would provide a copy of the LIC 500 no later than end of day Monday 03/03/2025. As of the time of the visit the Administrator has still not provided CCLD with a copy of the facility's LIC 500. No deficiencies were observed during today’s inspection. The Administrator did not respond to phone calls from the LPA at the time the report was delivered. S1 has signed this report on the facility's behalf. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 3, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:15 AM to conduct an unannounced Case Management – Other inspection at the facility today. LPA met with facility staff member Keyna Nkumbula (S1) who contacted the facility Administrator Elba Khachatryan entrance interview conducted and the reason for the visit was explained. The Administrator stated that they were unable to come to the facility at the time of the visit but has designated S1 to receive this report on their behalf. During today’s visit LPA conducted a physical plant tour and interviewed six (6) residents. No immediate health and safety concerns were observed. All residents interviewed stated that they are fed well, staff were present at the facility all night, and medications were given. No residents interviewed had concerns with the facility at the time of the inspection. LPA spoke with the Administrator via telephone call and requested a copy of the facility's LIC 500. The Administrator stated that they would provide a copy of the LIC 500 no later than end of day Monday 03/03/2025. No deficiencies were observed during today’s inspection. The Administrator was unable to come to the facility at the time of the inspection but has designated S1 to sign on their behalf. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 2, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:30 AM to conduct an unannounced Case Management – Other inspection at the facility today. LPA met with facility staff member Keyna Nkumbula (S1) who contacted the facility Administrator Elba Khachatryan entrance interview conducted and the reason for the visit was explained. The Administrator stated that they were unable to come to the facility at the time of the visit but has designated S1 to receive this report on their behalf. During today’s visit between 10:32 AM and 1:00 PM, LPA conducted a physical plant tour, conducted a medication audit for three (3) residents, conducted a brief file review for six (6) residents, interviewed six (6) residents, one (1) staff member, and attempted to interview one (1) guest. The following was observed. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. BEDROOMS: LPA observed three (3) resident bedrooms. All bedrooms were observed to be furnished appropriately. BATHROOMS: LPA observed one (1) common resident bathroom. The bathroom appeared to be clean and in good repair. Continued on LIC 809C. COMMON AREAS / OUTDOOR AREAS: LPA observed the common areas of the facility to be clean and in good repair. LPA observed cameras located throughout the outdoors of the facility. At 10:43 AM LPA observed the garage door to be open and unsecured. LPA observed the garage to contain bleach and other cleaning chemicals accessible to clients in care. Additionally, the garage was observed to contain additional food and water supplies. LPA advised the Administrator via telephone call that they were previously cited for a violation of CCR 87309(a) on 10/22/2024. LPA advised Administrator that a civil penalty in the amount of $250 will be assessed due to a repeat violation of the same regulation within a 12-month period. INTERVIEWS: LPA interviewed six (6) residents. All residents interviewed stated that staff members are always present on site at the facility. All residents interviewed stated that they facility provides them with ample amounts of food and provides meals at appropriate times. One (1) resident interviewed (R1) stated that they had no clean pants or undergarments to wear. This resident stated that their laundry is done once a week. LPA interviewed S1, S1 stated that they do R1’s laundry once a week as it has to be done separately from other resident’s laundry. S1 retrieved a clean pair of undergarments for R1 and confirmed that they would do a load of laundry for R1 at the time of the visit. LPA informed S1 that the garage of the facility was unlocked and accessible to clients in care. S1 secured the garage at the time of the visit. During the visit LPA observed a guest (G1) who stated they were there to visit S1. MEDICATION REVIEW: LPA reviewed medications for three (3) of six (6) residents. LPA observed all three (3) resident’s centrally stored medication and destruction record sheets (CSMDR) to contain the incorrect dates for medications filled. LPA observed three (3) residents to have medications stored in their medication boxes that were not listed on their CSMDR. LPA observed one (1) resident’s medication to not be administered as prescribed. LPA asked S1 to clarify the discrepancy. S1 stated that the medication arrived yesterday while staff #2 (S2) was on shift. S2 informed S1 that the resident refused to take the medication, and they logged the refusal. S1 attempted to find the refusal log but was unable to provide LPA with proof of medication refusal. During today’s visit LPA also discussed the staff schedule with S1 who confirmed that S1 and S2 are the primary staff at the facility and there is 24-hour presence of staff at the facility at all times. A current LIC 500 was not available, but the Administrator stated that they would email a copy of the LIC 500 to LPA later today. Continued on LIC 809C. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): The Administrator was unable to come to the facility at the time of the inspection but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 1, 2025

87309 Storage Space and Access (a) ... the licensee shall ensure that disinfectants, cleaning solutions... and other similar items... are in locked storage... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the garage containing cleaning and laundry chemicals was left unsecured which poses an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 1, 2025

Plan of correction: Facility staff secured the garage at the time of the visit. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a)(14) · Plan of correction due date: Mar 1, 2025

87468.2 Additional Personal Rights... (a) In addition to the rights... (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as one resident did not have their laundry done in a timely manner which left them with no clean pants or shorts to wear which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 1, 2025

Plan of correction: Facility staff agreed to do the resident's laundry at the time of the visit. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(D) · Plan of correction due date: Mar 15, 2025

87465 Incidental Medical and Dental Care (h) The following...shall apply... (6) The licensee shall be responsible for assuring that a record...is maintained... and includes: (D) The date filled. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as three residents CSMDR sheets had the incorrect dates of when the perscriprion was filled which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Mar 1, 2025

Plan of correction: Licensee will submit an accurate CSMDR sheet for the three residents to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(4) · Plan of correction due date: Mar 15, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as one resident's medication was not administered and staff were unable to proide proof of medication refusal which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Mar 1, 2025

Plan of correction: Licensee will submit either, their plan on how they will ensure medications are given as perscribed or proof of medication refusal for the identified resident to CCLD no later than POC due date.

Allegation investigated: Staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint visit for the above allegation. LPA arrived to the facility at 02:17 PM and met with facility staff Keyna Nkumbula. Facility staff contacted the facility administrator via telephone call. The facility administrator was unable to come to the facility at the time of the investigation. Entrance interview conducted and the reason for the visit was explained. During the initial complaint visit on 01/07/2025 between 09:48 AM and 02:00 PM LPA conducted a physical plant tour, reviewed five (5) resident files, interviewed four (4) residents, one (1) staff member, and the facility administrator. During today’s visit between 02:17 PM and 02:30 PM LPA conducted a brief physical plant tour, collected copies of relevant documentation, and interviewed one (1) staff member. Continued on LIC 9099C. Substantiated The allegation of “Staff did not safeguard resident's personal belongings.” alleges that facility staff signed for the delivery of a hospital bed and wheelchair for Resident #1 (R1) which R1 never received and the items are now missing. On 01/07/2025 LPA received an email from Witness #1 (W1). The email contained a photocopy of two (2) delivery tickets dated 09/26/2023 and 10/05/2023 from MedLife MediCal Supply Inc. The delivery ticket dated 09/26/2023 specified that the items delivered were: a standard wheelchair and additional accessories for the wheelchair. The delivery ticket dated 10/05/2023 specified that the items delivered were: a hospital bed and additional accessories for the hospital bed. LPA Byrne reviewed the bottom of the delivery ticket. This section stated, “I confirm that Medicare or my insurance has not purchased or rented similar items to the ones being delivered unto me today…” LPA confirmed that the name at the bottom of the delivery ticket was Keyna Kumbula (Keyna Nkumbula) (S1) and the signature matched that of previous reports signed by S1. The reason given for why the patient (R1) could not sign the delivery ticket was, “Patient Unable”. During today's interview with S1 LPA Byrne showed them the signature at the bottom of the delivery document. S1 confirmed that the signature matched their own. Based on the information obtained during interviews and record review there is sufficient evidence to support the allegation of Staff did not safeguard resident's personal belongings. Therefore, the allegation is deemed Substantiated at this time. The facility administrator was unable to come to the facility at the time of the investigation but has designated staff member Keyna Nkumbula to sign this report on their behalf. The report was read to the facility administrator via telephone call. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 29-AS-20250103170627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Jan 29, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1... (25) To protection of their property from theft or loss... This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as a hospital bed delivery was signed for by facility staff but the facility is unable to locate the hospital bed that was signed for which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 15, 2025

Plan of correction: Licensee will submit their plan on how they will correct this citation to CCLD no later than POC due date.

Allegation investigated: Staff is overcharging a resident in care.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint visit for the above allegation. LPA arrived to the facility at 09:46 AM and met with facility staff Kina Nkumbula. Facility staff contacted the facility administrator via telephone call. The facility administrator was unable to come to the facility at the time of the investigation. Entrance interview conducted and the reason for the visit was explained. During today’s visit between 09:48 AM and 02:00 PM LPA conducted a physical plant tour, reviewed five (5) resident files, interviewed four (4) residents, one (1) staff member, and the facility administrator. Continued on LIC 9099C. Substantiated The allegation of “Staff did not provide resident with an admission agreement.” alleges that R1 was not provided with a copy of their admission agreement. LPA interviewed R1 who stated that they remember the Administrator offering them a copy of the admission agreement at the time it was signed but they declined the offer of a copy as it was stored in their file at the facility. During the interview with the Administrator, they stated that copies of all signed documents are offered to the residents at the time they are signed. Additionally, the Administrator stated that R1 never asked for a copy of their admission agreement. Based on the information obtained during the interview and record review although the allegation may have happened or is valid there is insufficient evidence to support the allegation of Staff did not provide resident with an admission agreement. Therefore, the allegation is deemed Unsubstantiated at this time. The facility administrator was unable to come to the facility at the time of the investigation but has designated staff member Kina Nkumbula to sign this report on their behalf. The report was read to the facility administrator via telephone call. Exit interview conducted. A copy of the report was issued. The allegation of “Staff is overcharging a resident in care.” alleges that facility is over-charging Resident #1 (R1) for basic services. LPA Byrne interviewed Witness #1 (W1), W1 stated that R1 has been charged a monthly rate of $1492.82. PIN 23-20-CCLD titled “ESTIMATED SSI/SSP PAYMENT STANDARDS EFFECTIVE JANUARY 1, 2024” states that the approved amount payable for basic services for SSI recipients for the year of 2024 is not to exceed $1398.07. LPA Byrne interviewed the facility Administrator who stated that for the year of 2024 R1 was charged a flat rate of $1400.00 for basic services. The Administrator stated that the additional $92.82 is being charged as a combination of: a $75 late fee for payment received after the first of the month, a $50 monthly haircut fee, and additional snacks ordered by the residents that are not included on the facility’s menu. Interviews with R1 and Resident #2 (R2) revealed that haircuts are provided every 4-5 months or as needed. R1 and R2 confirmed that they order snacks from the Administrator and R2 was aware of the extra charges associated with ordering items not on the facility’s menu. LPA Byrne reviewed the resident’s admission agreement which states, “If requested, special food products purchased for an individual resident will be itemized on a monthly statement and charged at facility’s cost.” The facility Administrator stated that they have not provided an itemized lists of charges to those responsible for R1’s payments to the facility. Additionally, the Administrator stated that they have no receipts of the haircuts being provided to the residents as it was a cash transaction between the facility and a third-party vendor. Based on the information obtained during interviews and record review there is sufficient evidence to support the allegation of Staff is overcharging a resident in care. Therefore, the allegation is deemed Substantiated at this time. The facility administrator was unable to come to the facility at the time of the investigation but has designated staff member Kina Nkumbula to sign this report on their behalf. The report was read to the facility administrator via telephone call. The following deficiencies were cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 29-AS-20250103170627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(e) · Plan of correction due date: Jan 21, 2025

87464 Basic Services (e) If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as a late fee of $75 was charged to an SSI resident in addition to the cost of basic services which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Licensee will submit their plan on how they will correct this citation to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 21, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as an itemized list of extra food service charges was not provided to the party responsible for R1's payments to the facility which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Licensee will submit a statement of understanding confirming that they will adhere to all aspects of the resident's admission agreement. Additionally, the licensee will submit a copy of the breakdown of charges for R1.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced Case Management- Deficiencies inspection. During record review LPA observed Resident #1’s (R1) file. R1’s file was observed to contain an incomplete hospice care plan. Resident #2’s (R2) file was observed to contain blank pre-placement appraisal information, appraisal needs and services plan, and client personal property and valuables sheets. Additionally, R2’s file was missing a physician’s report. Resident #3’s (R3) file was observed to have an admission date of 09/25/2024 and a physician’s report dated 01/12/2023 which is outside of the required 12-month timeframe required prior to admission. Interviews with the facility Administrator revealed that they charge resident’s additional fees for requested snacks that are not normally available on the facility’s menu. The facility’s admission agreement states, “If requested, special food products purchased for an individual resident will be itemized on a monthly statement and charged at facility’s cost.” The Administrator stated that they have not provided resident’s representatives with an itemized receipt for these purchases. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Jan 21, 2025

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs... This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as R2's file did not contain a filled out pre-admission appraisal which poses a potential health, safety, and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Licensee will submit the completed pre-admission appraisal for Resident 2 to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87218(a)(1) · Plan of correction due date: Jan 21, 2025

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program... (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as R2's file did not contain a filled out resident personal property and valuables sheet which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Licensee will submit proof of a filled out property and valuables sheet for R2 to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Jan 21, 2025

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment...made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as R2's file did not contain a medical assessment and R3's file contained an assessment dated 20 months prior to their admission which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Licensee will submit updated medical assessments for R2 nd R3 to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b) · Plan of correction due date: Jan 21, 2025

87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as R1's file contained incomplete hospice paperwork which poses a potential health, safety, and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Licensee will submit completed hospice paperwork for R1 to CCLD no later than POC due date.

Allegation investigated: Staff did not secure knives/sharp objects making them accessible to residents Staff locked refrigerator House rules violate residents personal rights

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 01:47 PM. LPA met with the facility staff who contacted the facility administrator Elba Khachatryan via telephone call. The administrator arrived to the facility at 02:30 PM, the reason for the visit was explained, and entrance interview was conducted. During today’s visit LPA conducted a physical plant tour, interviewed residents, interviewed facility staff, and interviewed the facility administrator between 01:50 PM and 02:28 PM. Continued on LIC 9099C. Substantiated The allegation of “Staff did not secure knives/sharp objects making them accessible to residents” alleges that facility staff do not properly secure knives and other sharp objects from clients in care. During the physical plant tour LPA Byrne asked facility Staff #1 (S1) where knives are stored in the kitchen. S1 directed LPA to a drawer where knives, scissors, and other utensils were stored. At 02:05 PM LPA observed a locking mechanism on the drawer that was broken and failed to properly secure the drawer. LPA interviewed Administrator and S1 and asked when they noticed the drawer lock was broken. Both the Administrator and S1 stated that they did not notice until today (10/22/2024). During the visit facility staff replaced the locking mechanism. LPA confirmed that the drawer now properly latches making its contents inaccessible to clients in care. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of Staff did not secure knives/sharp objects making them accessible to residents. Therefore, the allegation is deemed Substantiated at this time. The allegation of “Staff locked refrigerator” alleges that facility staff secure the contents of the facility’s refrigerator making its contents unavailable to clients in care. During the physical plant tour LPA observed the facility refrigerator to contain a child proofing device on the left side. S1 opened the refrigerator and LPA observed foods, drinks, condiments, and snacks inside. LPA interviewed Administrator and S1 and asked the reasoning for the refrigerator being secured. S1 did not know the reason for the fridge being secured. The Administrator stated that the facility had a resident in the past that would enter the kitchen and try to cook, although the Administrator confirmed that the resident no longer resides at the facility and there is no current reason to keep the refrigerator secured. The Administrator agreed to remove the lock from the side of the refrigerator. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of Staff locked refrigerator. Therefore, the allegation is deemed Substantiated at this time. Continued on LIC 9099C. The allegation of “House rules violate residents personal rights” alleges that the house rules of the facility are a violation of the resident’s personal rights. During the physical plant tour LPA observed the house rules posted in the living room of the facility. LPA reviewed the facility’s house rules and observed some that are violations of resident’s rights. LPA observed the house rules to contain the following lines: “To cooperate with all staff and take medication assigned by doctor on schedule unless otherwise instructed by the assigned doctor”, “Residents may bring their smaller sized belongings”, “Silver Light Care is to inspect and inventory all residents belongings”, and “No homemade food is allowed by families except restaurant orders accompanied with receipt.” LPA interviewed the Administrator. The Administrator stated that the house rules are new and less than one year old. The Administrator stated that they made the house rules themselves and did not review the resident’s personal rights prior to making the rules. The Administrator agreed to change the house rules and send an updated version to the LPA for approval. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of House rules violate residents personal rights. Therefore, the allegation is deemed Substantiated at this time. The following deficiencies were cited (refer to LIC 9099Ds). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 29-AS-20241017091640

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 22, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation and interview the licensee failed to comply with the section cited above as the locking mechanism on the drawer containing knives and other sharp objects was broken making the items accesable which poses an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: Licensee repaired the locking mechanism at the time of the visit POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 5, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in...care facilities for the elderly shall have...rights: (2) To be accorded... comfortable accommodations, furnishings and equipment. Based on observation and interview the licensee failed to comply with the section cited above as Some house rules violate personal rights and the fridge was locked to clients in care which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: The lock on the fridge was removed at the time of the visit. Licensee will submit ann updated list of house rules to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced Case Management- Deficiencies inspection. During the physical plant tour LPA observed a food storage shelf located in the storage room in the backyard of the facility. LPA observed expired food items on the shelf. LPA observed five (5) jars of peanut butter, two (2) bottles of ketchup, four (4) boxes of pasta, and one (1) jar of tomato paste to be past their expiration dates. Facility staff removed the items and agreed to dispose of the at the time of the visit. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Nov 5, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality... This requirement is not met as evidenced by: Based on observation the licensee failed to comply with the section cited above as 5 jars of peanut butter, 2 bottles of ketchup, 4 boxes of pasta, and 1 jar of tomato paste were found to be past their expiration dates which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: Licensee will conduct an audit of all food supplies at the facility and will dispose of all expired items. Licensee will submit a photo of disposed items to CCLD no later than POC due date.

Allegation investigated: Facility staff did not provide assistance in meeting resident's medical needs Facility staff denied resident access to personal belongings

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced subsequent complaint visit for the above allegations. LPA arrived to the facility at 02:51 PM and met with facility staff Kina Nkumbula. Facility staff contacted the facility administrator via telephone call. The facility administrator was unable to come to the facility at the time of the investigation. Entrance interview conducted and the reason for the visit was explained. During the initial complaint visit on 10/02/2024, the LPA conducted a physical plant tour, conducted interviews with the administrator, one (1) staff member, and two (2) residents between 02:49 PM and 04:20 PM. LPA obtained copies of pertinent documents relevant to the investigation. During today’s visit on 10/16/2024 LPA conducted a brief physical plant tour, conducted an additional staff interview with Staff #1 (S1) and delivered the complaint investigation findings. Continued on LIC-9099C Unsubstantiated The allegation of “Facility staff did not provide assistance in meeting resident's medical needs” alleges that the facility failed to call 911 in response to a medical emergency for Resident #1 (R1). LPA Byrne interviewed Staff #1 (S1) who stated that on 09/10/2024 R1 sat in a chair in the living room of the facility and began exclaiming, “I am having a seizure, I’m having a seizure.” S1 told R1 to stay calm and began putting on gloves to assist. R1 then got out of the chair and walked to the backyard of the facility before S1 could put on the gloves. S1 was then informed that R1 had called 911 for themselves. S1 confirmed that they heard the sirens of EMS approaching and stated that R1 came back inside the facility and returned to the living room and waited for EMS to arrive. S1 confirmed that R1 had not expressed any complaints of chest pain or anxiety prior to the arrival of EMS and had not asked S1 for any additional assistance. Based on the information obtained during the interview and record review although the allegation may have happened or is valid there is insufficient evidence to support the allegation that facility staff did not provide assistance in meeting resident's medical needs. Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Facility staff denied resident access to personal belongings” alleges that facility staff withheld R1’s personal belongings after they were requested. During the initial complaint investigation LPA Byrne interviewed S1 who was alleged to have withheld R1’s belongings. S1 stated that R1 had asked the facility to centrally store their driver’s license and debit cards for safekeeping as they were afraid of losing the items. S1 stated that on 09/10/2024 R1 had called 911. Once first responders arrived R1 requested to be transported to the hospital and requested to bring their driver’s license and debit card. S1 stated that they initially did not provide the items as they required permission from the administrator. S1 stated that they reached out to the facility administrator to ask for guidance. After speaking with the facility administrator via telephone call the administrator advised S1 to provide the personal belongings. S1 then provided the driver’s license and debit card to R1 to take with them. S1 stated that the approximate timeframe from when the request for the items was made to when they were provided was about five (5) to ten (10) minutes. S1 stated that the whole interaction with EMS was around thirty (30) minutes. Based on the information obtained during the interview although the allegation may have happened or is valid there is insufficient evidence to support the allegation that facility staff denied resident access to personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC-9099C The facility administrator was unable to come to the facility at the time of the investigation but has designated staff member Kina Nkumbula to sign this report on their behalf. The report was read to the facility administrator via telephone call. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 29-AS-20240924100206

Type of visit: POC

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced plan of correction (POC) case management visit to the facility above. The reason for this visit was to conduct a follow-up in reference to deficiencies that were cited during a case management visit that occurred on 09/20/2024. The LPA met with facility staff member Kina Nkumbula, at 02:46 PM and explained the purpose of the visit. Facility staff contacted the facility administrator Elba Khachatryan who arrived at the facility at approximately 03:00 PM. Entrance interview conducted and the reason for the visit was explained. During today’s visit LPA Byrne interviewed the facility administrator. The facility administrator stated that they have not had time to submit the statement of understanding required to satisfy the POC for the deficiency that was cited. LPA informed the administrator that the POC is now considered late. The facility administrator was advised during the original complaint investigation that failure to correct deficiencies would lead to additional penalties. The facility administrator did not provide the LPA with the required documentation within the appropriate timeframe. As this is a failure to correct the POC within the given timeframe and no extension was requested a civil penalty is being assessed in the form of $500. The total of the civil penalty is calculated at $100 per day starting after the due date of the POC. The POC for this deficiency was due on 09/27/2024 and today’s date is 10/02/2024. LPA informed administrator that failure to correct the deficiency may lead to additional penalties. Exit interview conducted, civil penalty assessed, appeal rights provided, and a copy of the report delivered.the state’s words, verbatim · CDSS document, Oct 2, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management – Deficiencies visit at 10:12 AM. LPA met with facility staff who contacted Administrator Elba Khachatryan via telephone call. LPA explained that the visit was in reference to a 3-day eviction notice issued without prior approval from CCL. On 09/13/2024, LPA Emily Peraldi spoke with Administrator Elba Khachatryan regarding an incident report pertaining to Resident #1 (R1) of which R1 was threatening harm to residents and staff. A 3-day eviction was discussed, and LPA Peraldi advised the Administrator that CCL would need to review and approve the notice prior to issuance. On 09/16/2024, LPA Byrne was advised by the Administrator that they issued the 3-day eviction notice to R1 without CCL approval and R1 relocated on 09/15/2024. Between 10:14 AM and 10:45 AM, LPA conducted a brief physical plant tour, interviewed staff, interviewed residents, and reviewed pertinent documentation relevant to the incident. Interviews conducted and records review revealed that R1 is no longer residing at the facility. Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4) stated that they had overheard R1 making threats to staff previously. Staff 1 (S1) and staff 2 (S2) stated that they had previously been directly threatened by R1. LPA informed facility staff and facility administrator that all 3-day evictions are required to be approved by CCL prior to their issuance to a resident. The facility administrator was unable to sign the report and has designated facility staff Edgar Khachatryan to sign on their behalf. This report was read to the facility administrator via telephone call. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted, appeal rights were discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Sep 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(b) · Plan of correction due date: Sep 27, 2024

(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause...behavior which is a threat to ...health or safety of others in the facility. Based on interviews and record review the licensee did not comply with the section cited above as R1 was served a 3-day eviction notice without prior approval from CCL. This posed a potential personal rights risk to the client in care.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Licensee will submit a statement of understanding stating that they have reviewed the entirety of CCR 87224 to CCL no later than POC due date.

Allegation investigated: Facility retained resident with a higher level of care needs.

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a subsequent visit to investigate the allegation listed above. The LPA was greeted by staff and informed them of the reason for the visit. Staff contacted Administrator on the phone and LPA explained the reason for the visit, and the LPA read the report over the phone. Administrator was unable to come to the facility and allowed staff to sign off on the report. On 03/20/2024, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct an initial 10-day visit to investigate the allegation listed above. The LPA was greeted by staff and informed them of the reason for the visit. Staff contacted Administrator on the phone and LPA explained the reason for the visit. Administrator stated that they would arrive shortly. The Administrator arrived at 11:35 a.m. The LPA interviewed the staff at 11:08 a.m. and the administrator at 11:45 a.m. Additionally, the LPA requested the documents pertaining to the allegation. Continues on LIC 9099C... Unsubstantiated On the allegation that the ‘facility retained a resident with a higher level of care needs’, it is the concern of the complainant that the resident 1 (R1) has become too ill to be in this facility. The R1 was found to be experiencing shortness of breath and no oxygen was available in the facility. The LPA conducted record review, and R1’s physician report dated 01/16/2024, states that R1’s primary diagnosis is neuropathy, sciatica, dermatitis, and muscle weakness, and secondary diagnosis as anxiety. Furthermore, record review of medical records from a rehabilitation center dated 12/13/2023, also state that the primary diagnosis is neuropathy, sciatica, and muscle weakness. No records were found with diagnosis of breathing problems or the need to use oxygen. On 07/09/2024, LPA Urena interviewed R1 from 12:15 p.m. to 1:17 p.m. The interview revealed that on 03/03/2024, R1 was experiencing shortness of breath while in the bathroom. The R1 called the staff to assist them and to tell them that they could not breathe. The staff asked if R1 wanted them to call 911 and the R1 stated, ‘Yes’. Emergency Medical Team personnel arrived and transported R1 to the hospital where physicians found clots in R1’s lungs and diagnosed it as pulmonary embolism without acute pulmonale. The R1 stated that they were not aware that they had clots. When asked if their primary doctor had order oxygen for their use, R1 denied ever having the need to use oxygen. Although, R1’s level of care became higher at the time of the hospitalization, the facility was not aware nor noticed any changes in the level of care for R1 before the incident took place on 03/03/2024. The facility followed protocol to assist the R1 in the time of critical need and was able to get help in a timely manner. Therefore, the allegation that the facility retained resident with a higher level of care needs, is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 29-AS-20240313111140

Allegation investigated: Facility staff hit resident Facility staff lock resident in their room

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:28 a.m., the LPA met with staff and explained the reason for the visit. At 9:49 a.m., the Administrator Elba Khachatryan arrived at the facility. During the time of the visit, the Administrator left and authorized staff, Keyna Nkumbula, to sign the report. Between 9:30 a.m. and 12:10 p.m., the LPA conducted interviews with four (4) residents and one (1) staff. At 9:40 a.m., the LPA conducted a physical plant tour. At 9:51 a.m., the LPA conducted an interview with the Administrator. At 10:06 a.m., the LPA requested and obtained copies of pertinent documents. At 11:22 a.m., the LPA conducted a telephonic interview with a resident’s family member. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Facility staff hit resident. On 06/26/2024, the Department received a complaint alleging that facility staff hit Resident #1 (R1). No further information was provided from the complainant including names of staff. During the initial visit, the LPA conducted interviews with four (4) out of four (4) residents. Resident interviews denied staff hitting residents. The interviews revealed that the residents feel safe at the facility. No safety concerns were brought up during the resident interviews. Staff #1 (S1) denied hitting R1. S1 stated that they have not witness other staff hit R1 or other residents in care. The Administrator indicated that they had not witnessed staff hit or mistreat residents, including R1. Additionally, the LPA had a telephonic interview with R1’s family member; R1’s family member did not reveal any concerns regarding staff. 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: Facility staff lock resident in their room. On 06/26/2024, the Department received a complaint alleging that facility staff lock Resident #1 (R1) in their room. No further information was provided from the complainant. Resident interviews revealed that staff do not lock them in their rooms. Residents stated that the door handles do not have locks. No safety concerns were brought up during the resident interviews. Administrator and Staff interviews revealed that the resident rooms do not lock and that only the front and back doors remain locked for safety reasons. The LPA observed resident rooms doors open during the time of the visit and did not observe locks on resident door handles. 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 issued.the state’s words, verbatim · CDSS document, Jul 1, 2024 · control 29-AS-20240626155102

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 2:40 p.m., the LPA met with staff and explained the reason for it visit. At 3:04 p.m., the Administrator arrived at the facility. At 2:50 p.m., the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Starting at 3:19 p.m., the LPA conducted an interview with three (3) residents and one (1) staff. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 2:53 p.m., hot water measured at 105.5-degree Fahrenheit. Cleaning supplies are stored in locked cabinet under the sink. BEDROOMS: The facility is a single-story residential home with three (3) bedrooms for resident use. 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. RESTROOMS: The facility has two (2) bathrooms. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 2:55 p.m., hot water measured at 108.7-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. OUTDOOR SPACE: At 2:57 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on each side of the house designated for an emergency exit. The garage is detached and remains inaccessible to residents. Passageways were free and clear from obstruction. A fenced, and locked swimming pool is found in the back of the house. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last purchased on 03/12/2024. At 2:59 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. First aid kit is located near the kitchen. Medications are stored in locked filing cabinet located between the kitchen and common areas. Due to time constraints the LPA will return to complete the annual at a later date. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 30, 2024