Mary's Chateau III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:40 AM. LPA met with facility staff who contacted the facility Administrator Mary Petikyan via telephone call. The facility Administrator arrived to the facility at 10:58 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 11:00 AM, the LPA, along with facility 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: LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. LPA observed a secured drawer which contained knives and a secured under sink cabinet which contained cleaning supplies. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. BEDROOMS: There are seven (7) bedrooms in the facility; six (6) are designated as single occupancy resident rooms and one (1) is designated as the staff room. LPA and facility Administrator toured all seven (7) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on facility exits and were functional at the time of the visit. LPA observed the staff bedroom to be properly secured. Additionally, the staff room contained an extra refrigerator, an adequate supply of emergency water, and extra care supplies. CONTINUED ON LIC 809C. COMMON AREAS: This included the living room, dining room, hallway, and entryway. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television, activities for resident use, and a fireplace. The dining room was observed to be clean and contained adequate seating for resident use. LPA observed the hallway to contain a secured laundry room which contained a washer and dryer as well as detergents and cleaning supplies. LPA observed a hallway closet which contained clean linens for resident use. LPA observed two (2) fire extinguishers throughout the facility that were fully charged and were last purchased on 05/01/2026. Smoke detectors and carbon monoxide detectors were tested at 01:51 PM and were functional at the time of the visit. LPA observed the entryway to contain the infection control point/sign in sheet. LPA observed an unsecured cabinet of the infection control point to contain an unsecured resident medication bottle. LPA notified the Administrator who immediately secured the items. The Administrator explained that the medications were discontinued/expired and were scheduled to be appropriately disposed of. LPA informed the Administrator that Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. The Administrator expressed understanding and agreed to ensure proper storage of centrally stored medications at the facility. BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as shared resident bathrooms and one (1) is designated as a private resident bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 105.8 and 109.0 degrees Fahrenheit, which is in compliance with regulation. Two (2) resident bathrooms were observed to contain appropriately secured storage cabinets that contained resident grooming supplies. OUTDOOR SPACE: The facility had two (2) emergency exit gates located in the front yard. The facility had adequate shaded seating outdoors for resident use. LPA observed two (2) appropriately secured sheds which contained gardening supplies, care supplies, and decorations. LPA observed cameras located on the exterior of the facility. CONTINUED ON LIC 809C. RECORD REVIEW: Record review began at 11:32 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. Six (6) staff files were reviewed. All staff files contained the required documents and trainings. Six (6) resident files were reviewed. All resident files reviewed contained all required documentation. During file review LPA observed two (2) incident reports located in resident files. LPA conducted a file review and did not observe that these incident reports were submitted to Community Care Licensing Division (CCLD). LPA notified the Administrator who stated that they believed the reports were faxed to CCLD within the required timeframe. LPA confirmed with Regional Office (RO) staff that the incident reports were not received by CCLD. LPA reminded the Administrator that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of the event. The Administrator expressed understanding and agreed to submit all future incident reports to CCLD within the required timeframe. MEDICATION REVIEW: Medication review began at 01:30 PM. Medications are stored centrally and securely in a cabinet in the living room. Medications for three (3) residents were observed. All medications observed were documented appropriately on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. 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 they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly and the last emergency disaster drill was conducted on 07/23/2026. 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. INTERVIEWS: LPA interviewed one (1) staff and two (2) residents. The residents interviewed stated that staff treat them well and are attentive to their needs. The residents interviewed had no concerns with the facility. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse. CONTINUED ON LIC 809C. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations and/or the Health and Safety Code, 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, Aug 17, 2026

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:14 AM. LPA met with facility staff who contacted the facility Administrator Mary Petikyan via telephone call. The facility Administrator arrived to the facility at 10:26 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:26 AM, the LPA, along with facility 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: LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. LPA observed a secured drawer to contain knives as well as a secured cabinet located under the sink which contained cleaning supplies. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed the facility’s non-perishable food supply to contain four (4) cans of food that were approximately one (1) month past their expiration date and one (1) additional can that was dented. LPA informed the Administrator, who immediately removed the cans from the storage. Additionally, during the visit the Administrator conducted an audit of the facility’s food supplies to ensure no items near their expiration date were retained. BEDROOMS: There are seven (7) bedrooms in the facility; six (6) are designated as single occupancy resident rooms and one (1) is designated as a staff room. LPA and facility Administrator toured all seven (7) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on facility exits and were functional at the time of the visit. LPA observed the staff bedroom to be properly secured. Additionally, the staff room contained an extra refrigerator, an adequate supply of emergency water, and extra care supplies. Report Continued on LIC 809-C BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as shared resident bathrooms and one (1) is designated as a private resident bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 106.2 and 109 degrees Fahrenheit, which is in compliance with regulation. Two (2) hallway bathrooms were observed to contain appropriately secured storage cabinets that contained resident grooming supplies. COMMON AREAS: This includes the living room, dining room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television, activities for resident use, and an appropriately screened fireplace. The dining room was observed to be clean and contains adequate seating for resident use. LPA observed the hallway to contain a secured laundry room that contained a washer and dryer as well as detergents and cleaning supplies. Additionally, LPA observed a hallway closet to contain clean linens for resident use. All furniture throughout the facility was observed to be clean and in good repair. The LPA observed two (2) fire extinguishers throughout the facility to be fully charged and purchased on 04/24/2025. Smoke detectors and carbon monoxide detectors were tested at 10:57 AM and were functional at the time of the visit. OUTDOOR SPACE: The facility has two (2) emergency exit gates located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed two (2) appropriately secured sheds to contain gardening supplies and decorations. LPA observed cameras located on the exterior of the facility. RECORD REVIEW: Record review began at 11:00 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. Six (6) staff files were reviewed. All staff files contained the required documents. Six (6) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review. MEDICATION REVIEW: Medication review began at 12:25 PM. Medications are stored centrally and securely in a cabinet in the living room. Medications for two (2) residents were observed. All medications observed were documented appropriately on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Report Continued on LIC 809-C 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 they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly and the last emergency disaster drill was conducted on 07/14/2025. 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. INTERVIEWS: LPA interviewed one (1) staff and one (1) resident. The resident interviewed stated that staff treat them very well and are attentive to their needs. The resident interviewed had no concerns with the facility. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident rights, the different 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 liability insurance. 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, Sep 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:16 AM. LPA met with facility staff who contacted the facility administrator Mary Petikyan via telephone call. Facility administrator arrived to the facility at 09:32 AM Entrance interview conducted and the reason for the visit was explained. Beginning at 09:35 AM, the LPA, along with facility 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 were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives as well as a secured cabinet located under the sink which contained cleaning supplies. The LPA observed fire extinguishers throughout the facility to be fully charged and purchased on 07/12/2024. BEDROOMS: There are six (6) bedrooms in the facility; all six (6) are single occupancy and all are designated for resident use. LPA and facility administrator toured all six (6) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom number six (#6) is designated as the bedridden approved room and contains a direct exit to the front yard. One resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and were functional at the time of the visit. LPA observed one (1) appropriately secured room, designated as a staff break room, to contain an extra refrigerator, an adequate supply of emergency water, and extra care supplies. Report Continued on LIC 809-C BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as shared resident bathrooms and one (1) is designated as a private resident bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 106.3 and 110.1 degrees Fahrenheit, which is in compliance with regulation. COMMON AREAS: This includes the living room, dining room, and a seating area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains an appropriately screened fireplace. Smoke detectors and carbon monoxide detectors were tested at 1:53 p.m. and were functional at the time of the visit. The dining room was observed to be clean and contains adequate seating for resident use. The seating room was observed to be clean with adequate seating. LPA observed a secured laundry room to contain a washer and dryer as well as detergents and cleaning supplies. LPA observed a hallway closet to contain an adequate amount of emergency food supplies. OUTDOOR SPACE: The facility has two (2) emergency exit gates located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. The backyard contains two (2) sheds that were observed to contain extra care supplies as well as extra walkers. RECORD REVIEW: Record review began at 10:15 a.m. 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, TB tests, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents. Six (6) resident files were reviewed. All resident files reviewed contained all required documentation. MEDICATION REVIEW: Medication review began at 11:25 a.m. Medications are stored centrally and securely in a cabinet in the seating room. Medications for three (3) residents were observed. All medications observed were documented appropriately on their centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Report Continued on LIC 809-C 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. Last emergency disaster drill was conducted on 07/04/2024. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan were reviewed/updated on 07/01/2024 by the facility’s administrator. INTERVIEWS: LPA interviewed two (2) staff and two (2) residents. All residents interviewed stated that the food was of good quality and is provided in sufficient amounts. All residents stated that staff treat them very well and are attentive to their needs. No residents interviewed had concerns with the facility. The staff members interviewed were knowledgeable on their roles and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse. One (1) staff interview was conducted with the assistance of the administrator acting as a translator. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. No deficiencies were observed during today’s visit. Exit interview was conducted and a copy of today's report was issued.the state’s words, verbatim · CDSS document, Sep 5, 2024