Mom and Dads Retreat

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Karine Khojikyan, Staff. Armenui Arzumanyan, Administrator was contacted by staff and she arrived shortly to conduct the visit. The reason for today's visit was explained. The facility is a single storey home located in the back of the property consisting of 2 separate buildings with separate addresses. The home consists of a living room, dining room, kitchen, a den, 5 bedrooms and 4 full bathrooms. No bodies of water were observed on the premises. The facility is fire cleared for 5 NON- AMBULATORY and 1 BEDRIDDEN resident. Bedroom #3 is designated for bedridden use. On today's visit, LPA Yee reviewed the entire CARE Inspection Tool, 5 Resident and 6 Staff files, Plan of Operations, Disaster Preparedness and Infection Control Plan. The following were observed: the living room was observed furnished with a sofa, love seat, a desk, a built in bar, chairs and filing cabinets for staff and resident files behind the bar. The family room was observed with plenty of sitting, a dining table and 6 chairs, a fire place that is secured with a glass door and a permanent fire screen. the kitchen is equipped with the usual stove, dishwasher, oven and refrigerator. Food supply was reviewed in the pantry, refrigerator and the outside refrigerator, there was sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed. continued on LIC809-C Page 2. Located inside the panty is the only fire extinguisher purchased on 8/26/26. Bedrooms #1, #2, #4 and #5 are private rooms and are each furnished with a hospital bed, a night stand, a lamp, a chair, a dresser and a built in closet except for bedroom #5. Bedroom #5 has a portable closet and the room is currently vacant. The beds in bedroom #1 and bedroom #2 are equipped with 1/2 bed rails. Bedroom #3 was observed with 2 beds, 2 night stands, 2 chairs, 2 lamps and a walk in closet and a shared dresser. The bed located on the right side of the room was equipped with a 1/2 bed rail. The auditory device on the 3 outside exiting doors located in the living room, bedroom #1 and bedroom #3 were tested and were operational. Located inside bedroom #2, #3 and #4, all have a private bathroom. The bathrooms located inside bedroom #2 and #4 contained a walk in shower, a shower chair, grab bars, a slip resistant mat, a toilet with a riser. Water temperature was tested and read 115.5 degrees in bedroom #2 and 118.3 in bedroom #4. Bedroom #3 was observed with a walk in shower, a toilet with a riser, a bidet, grab bars, a slip resistant mat, 2 sink vanity and a jacuzzi bath tub. Water temperature read 115.9 degrees Fahrenheit. the common bathroom, located by the laundry area was observed with a walk in shower, chair, grab bars, a slip resistant mat, a single sink vanity, a toilet. Water temperature was tested and read 118.8 degrees Fahrenheit. the first aid kit and manual met Title 22 requirements. staff all have current first aid training. the facility has current general liability insurance that meets Title 22 requirements. the hardwired smoke detectors located inside the 5 resident rooms, hallway, living room an family room were tested and were operational. Per test, the combination smoke/carbon monoxide detectors are located in the hallway and living room. The fire rated doors on bedroom #1 and the resident hallway were activated when the smoke detectors were tested. centrally stored medications are stored in locked cabinets in the kitchen Cleaning solutions, disinfectants and toxins are stored in a locked cabinet in the laundry area and in a locked cabinet under the kitchen sink. continued on LIC809-C Page 3. knives are stored in a locked case inside a kitchen drawer. Per tour of the outside areas, a covered patio furnished with wicker chairs, a glass table and 4 chairs, storage cabinets and a refrigerator was observed. The trash cans are stored in the driveway of the front house. Overall, the outside areas were observed to be clean. No deficiencies were cited on today's visit. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Karine Khojikyan, Staff. Armenui Arzumanyan, Administrator was contacted by staff and she arrived at 10:20am to conduct the visit. The reason for today's visit was explained. The facility is a single storey home located in the back of the property consisting of 2 separate buildings with separate addresses. The home consists of a living room, dining room, kitchen, a den, 5 bedrooms and 4 full bathrooms. No bodies of water were observed on the premises. The facility is fire cleared for 5 NON- AMBULATORY and 1 BEDRIDDEN resident. Bedroom #3 is designated for bedridden use. On today's visit, LPA Yee reviewed the entire CARE Inspection Tool, 6 Resident and 6 Staff files, Plan of Operations, Disaster Preparedness and Infection Control Plan. The following was observed on today's visit: the living room was observed furnished with a sofa, love seat, a desk, a built in bar, chairs and filing cabinets for staff and resident files behind the bar. The family room was observed with plenty of sitting, a dining table and 6 chairs, a fire place that was secured with a glass door and a fire screen. continued on LIC809-C Page 2 the kitchen is equipped with the usual stove, dishwasher, oven and refrigerator. Food supply was reviewed in the pantry, refrigerator and the outside refrigerator, there was sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed. A recommendation was made to supplement the canned proteins with additional cans of chicken and fish. Located inside the panty is the only fire extinguisher purchased on 6/30/25. Bedrooms #1, #2, #4 and #5 were each furnished with a hospital bed, a night stand, a lamp, a chair, a dresser and a built in closet except for bedroom #5. Bedroom #5 has a portable closet. Bedroom #3 was observed with 2 hospital beds, 2 night stands, 2 chairs, 2 lamps and a walk in closet. a shared dresser. The auditory device on the door was tested and was operational. Located inside bedroom #2, #3 and #4, all have a private bathroom. The bathrooms located inside bedroom #2 and #4 contained a walk in shower, a shower chair, grab bars, a slip resistant mat, a toilet with a riser. Water temperature was tested and read 115.4 in bedroom #2 and 118.6 in bedroom #4. Bedroom #3 was observed with a walk in shower, a toilet with a riser, a bidet, grab bars, a slip resistant mat, 2 sink vanity and a jacuzzi bath tub. Water temperature read 115.5 degrees Fahrenheit. the common bathroom was observed with a walk in shower, chair, grab bars, a slip resistant mat, a single sink vanity, a toilet. Water temperature was tested and read 118.1 degree Fahrenheit. the first aid kit and manual met Title 22 requirements. the hardwired smoke detectors located inside the 5 resident rooms, hallway, living room an family room were tested and were operational. Per test, the combination smoke/carbon monoxide detectors are located in the hallway and living room. The fire rated doors for bedroom #1 and the hallway were operational. the auditory devices on the outside exiting doors in the living room, family room, bedroom #1 and bedroom #3 were operational. the facility has current general liability insurance that meets Title 22 requirements. centrally stored medications a re stored in locked cabinets in the kitchen Cleaning solutions, disinfectants and toxins are stored in a locked cabinet in the laundry area and in a locked cabinet under the kitchen sink. knives are stored in a locked case inside a kitchen drawer. continued on LIC809-C Page 3 Per tour of the outside areas, a covered patio furnished with wicker chairs, storage cabinets and a refrigerator was observed. The outside areas were observed to be clean. The trash cans are stored in the front by the gate. Per Administrator, new trash cans were ordered and are pending delivery. No deficiencies were cited on today's visit.the state’s words, verbatim · CDSS document, Sep 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:00 a.m. Upon arrival, LPA Mosley was greeted by staff and administrator and informed them of the visit. The LPA met with Administrator ARMENUI AMY ARZUMANYAN and explained the reason for the visit. The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a single story home located in the back of the property consisting of 2 separate buildings with separate addresses. The home consists of a living room, dining room, kitchen, a den, 5 bedrooms and 4 full bathrooms. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:45 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed fully charged and purchased on 08/02/2024. The LPAs observed required postings throughout the common space. The last emergency disaster drill took place on 07/15/2024. Activities were observed in the common areas. KITCHEN: The LPA inspected the kitchen/food service area at 11:05 a.m. Knives and sharps were observed in a lock box in a drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 114.8 degrees Fahrenheit at 11:09 a.m. Complete first aid kit and manual was observed at 11:06 a.m. LPA observed an adequate amount of emergency food and water in the food pantry. Report Continued on LIC 809C... Report Continued from LIC 809... BEDROOMS: There are 5 (five) total bedrooms in the facility; one (1) is designated as a shared room, four (4) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a washer and dryer on premises. Laundry detergent was observed in a locked cabinet above the washer and dryer. RESTROOMS: The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first private restroom measured at 114.2 degrees Fahrenheit at 11:13 a.m. The hot water temperature was measured; the second private restroom measured at 114.3 degrees Fahrenheit at 11:18 a.m. the third (3) private restroom measured at 115.2 degrees Fahrenheit at 11:26 a.m. The fourth (4) shared restroom measured at 114.2 at 11:32 a.m. all restrooms within the required range. BACKYARD/ OUTDOOR AREA: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. MEDICATIONS: Medications review began at approximately 2:45 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications for five (5) residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. RECORDS: Resident Records were reviewed beginning at 11:45 a.m. and personnel records at 12:45 p.m. five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Report Continued from LIC 809C... Report Continued from LIC 809... Six (6) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. INTERVIEWS: One (1) staff interview was conducted. Five (5) resident interviews were attempted, and three (3) interviews were conducted during the inspection. DOCUMENTS: Documents obtained during inspection include liability insurance and LIC 9020. No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Yee conducted an announced case management visit to inspect bedroom #1 that was altered to allow for the retention of a non-ambulatory resident in that room. Bedroom #1 was previously fire cleared for an ambulatory resident only. City permits were obtained for the alteration of bedroom #1 and fire cleared on 1/22/2024. The facility is now fire cleared for 5 NON-AMBULATORY residents and 1 BEDRIDDEN resident. Bedroom #3 is designated for use by bedridden resident. On today's visit, LPA Yee conducted a tour of the entire facility, inside and outside, with emphasis on Bedroom #1 and Bedroom #3 to ensure that there aren't any obvious visible safety issues. The entrance to Bedroom #1 was altered to include a 20 minute fire rated door and a door that leads directly to the outside. The hallway leading to Bedrooms #2 through to Bedroom #5 also has a 20 minute fire rated door that was previously installed when the facility was licensed to allow residents in those bedroom time to exit from Bedroom #3. Per today's inspection, LPA Yee did not observe any obvious safety issues with the facility and any issues that would prevent Bedroom #1 from being approved for use by a non-ambulatory resident. Effective as of today's visit, bedroom #1 is cleared for resident use. Exit interview was conducted a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 29, 2024