Tna Residential Care

Type of visit: Required - 1 Year

At 9:30 AM, Licensing Program Analysts (LPAs), Huma Rahimi, and Angela Panushkina, along with the Fire Inspector Linsay Pellegrini, conducted an unannounced annual inspection at the facility mentioned above. the team was greeted by the staff, Nazgul Rysalieva, who granted access to the facility. The Administrator was contacted via a telephone and LPAs explained the reason for the visit. The Administrator arrived at the facility at 11:05 AM. This facility is licensed for the capacity of six (6) Ambulatory residents. Upon arrival, Mrs. Akmakchyan informed LPAs that the facility currently has six (6) residents, of which one (1) is bedridden in bedroom #3 and three (3) are non-ambulatory. The team was also informed that none of the residents are on Hospice. At approximately, 10:00 AM, the team conducted a tour of the facility, and the following was observed: Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. No obstructions observed throughout the facility. The facility license was not posted and or available for review. Kitchen: The team observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. At 10:15am, all knives and other sharps were observed locked in the kitchen drawer. The team observed the medication cabinet in the kitchen unlocked and accessible to residents in care. There is a fire extinguisher by the dining area that was last purchased on 2/10/2026. Continue on LIC 809C Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms have appropriate bedding and linens. The team observed that bedroom #3 window was altered to a new door without proper permit from Los Angeles Department of Building and Safety (LADBS). Fire inspector reviewed the permit information and confirmed that there was no permit granted. The team also observed Resident #3 (R3) in bedroom #3 with the bedridden status on file and the facility is not licensed and fire cleared to retain a bedridden resident. Bathrooms: The team observed two (2) bathrooms for resident use and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The team observed appropriate grab bar and resident's bathroom had non-skid mat. The team observed appropriate hand washing signs posted in each bathroom. Outside areas: At approximately, 10:25 am, the team toured the outside area of the facility. The team observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Laundry: Laundry room is located outside and during the walk though, the team observed the room locked and inaccessible to residents in care. Resident/Staff Files: Between 10:45 AM - 12:00 PM, LPAs reviewed three (3) staff and sixt (6) residents files and observed all records updated and completed Medications review: At approximately, 12:30 pm, LPAs conducted a review of medication for residents in care. All records were observed to be complete and updated. Administrative: . LPAs collected a copy of Liability Insurance and LIC500. Deficiencies and civil penalty issued, see LIC809Ds. Exit interview conducted, appeal rights explained and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Other

At 9:30 AM, Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina conducted an unannounced Case Management – Other visit to the above facility. Upon arrival, LPAs met with facility staff Mari Ekmakchyan and the Administrator was contacted. LPAs explained the purpose of the visit. The Administrator arrived at 11:30 AM to the facility. During today’s visit, LPAs reviewed resident records and observed three (3) out of five (5) residents are non-ambulatory and two (2) out five (5) resident are ambulatory, despite the facility being licensed for six (6) ambulatory residents only. LPAs also explained that the non ambulatory residents (R1, R2, and R3) would need to be relocated and are not allowed to return until the fire clearance is approved. LPAs also addressed a fire safety compliance matter with facility staff. On 02/03/2026, a Pre-Inspection/Consultation conducted by the Los Angeles Fire Department (LAFD) revealed that the above-listed property was in violation of several sections of the Los Angeles Municipal Code (L.A.M.C.) related to fire prevention and life safety. The notice issued by LAFD ordered the facility to correct the violations within the specified timeframes and to contact the assigned Fire Inspector to schedule a compliance inspection by the designated compliance dates. The LAFD notice identified a total of seven (7) corrections that must be addressed in order for the facility to obtain an approved Fire Clearance. LPAs conducted an interview with the the Administrator and were informed that all violations are currently under the process of being corrected. LPAs also observed that three fire doors in room #1, 2 and 3 are already installed and awaiting for fire clearance approval by LAFD. LPAs also observed that Fire Extinguisher was last purchased on 02/12/2026. LPAs will conduct a follow-up case management visit for updated information. Continue on LIC 809C LPAs discussed the above matters with facility Administrator and advised that the facility must ensure continued compliance with licensing regulations, including maintaining appropriate administrative oversight, ensuring the care and supervision of residents, and addressing all fire safety corrections identified by LAFD. LPAs also requested to updated LIC500 (Personnel Report) with correct work/time/date information to reflect proper hours of work for the Administrator to be available at the facility. A deficiency issued and appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Mar 13, 2026

Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...(2) Bedridden persons... This requirement is not met as evidenced by: Based on observation during today's visit the licensee did not comply with the section cited above by failing to relocate non-ambulatory residents - R1, R2, and R3, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: The Administrator agreed to re-locate three (3) non-ambulatory residents until the fire clearance is obtained and approved. Licensee will provide re-location information via e-mail by the POC due date (03/13/26). Civil penalty will be assessed.

Type of visit: POC

At 9:30 AM, Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina conducted an unannounced Plan of Correction (POC) visit to the above-named facility to verify correction of deficiencies cited during the case management visit dated 10/13/2025. Upon arrival LPAs met with the staff #1 (S1), who granted access to the facility. LPA Rahimi requested the phone number for the Administrator. At 10:25am, LPA attempted to contact the Administrator, but no one answered. LPA left a voicemail with a call back number. During the prior complaint visit (control #31-AS-20250828113316) conducted on 09/02/2025 and a subsequent visit conducted on 10/13/2025 LPA also contacted the Administrator and both times the Administrator was unable to come to the facility. Therefore, the facility will be cited for not having Administrator available upon request. At 10:30 AM, Mari Akmakchyan, Staff #3, arrived to the facility and LPAs explained the purpose of the visit. During today’s visit, LPAs verified the status of three deficiencies previously cited. The first deficiency, cited under Title 22, Section 87211(a)(1)(D) – Reporting Requirements, was not cleared. Incident report involving Resident #2 (R2) which occurred in the last week of June 2025, was not submitted to Community Care Licensing (CCL). A new citation and civil penalty will be issued. LPAs were informed that the staff training on mandated reporting has not been conducted. The second deficiency, cited under Title 22, Section 87202(a) – Fire Clearance, also remains not cleared. LPAs observed two (2) non-ambulatory residents, identified as R3 and R4, still residing in the facility. The third deficiency, cited under Health and Safety Code Section 1569.17(a)(2) – Criminal Record Clearance. During today's visit, LPA conducted review of the facility guardian and observed that the staff (previously not being fingerprinted) is already associated with this facility. Continue on LIC 809C However, LPAs observed Staff #1 (S1) and Staff #2 (S2), currently present and providing direct care and supervision to residents are not fingerprint cleared and or associated with the facility. LPAs were informed that S1 started working since February 2025 and S2 started working as of today (11/13/2025). Based on today’s observations and interviews, three (3) out of three (3) deficiencies that were previously cited remain not cleared: failure to submit an Unusual Incident/Injury Report, exceeding approved fire clearance by retaining non-ambulatory residents, and Criminal Record Clearance by having two staff (S1 and S2) without proper fingerprint clearance and association to the facility . During today's visit, an additional deficiency was also observed and issued. Civil penalties were discussed and issued where applicable. A follow-up visit will be conducted to verify correction of the cited deficiencies. Deficiencies issued and appeal rights explained. An exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Nov 14, 2025

Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...(2) Bedridden persons... This requirement is not met as evidenced by: Based on observation during today's visit the licensee did not comply with the section cited above by not re-locating a bedridden and non-ambulatory residents without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Staff #3 (S3) agreed to re-locate resident with bedridden and non-ambulatory status until the fire clearance is obtained and approved. Licensee will provide re-location information via e-mail by the POC due date (11/14/2025). Civil penalty will be assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Nov 14, 2025

87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline. Based on interview and record review, the licensee did not comply with the section cited above by hiring S1 on 02/2025 and S2 on 11/13/25, without association and fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: S3 agreed to fingerprint cleared and associate S1 and S2 to the facility. The Licensee will submit the proof of correction to LPA by POC due date. Civil penalty assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Nov 14, 2025

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPAs, the licensee did not comply by failing to submit the incident report previously cited on 10/13/25. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: S3 shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R2's incident report is provided to LPAs during today's visit and POC is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Nov 20, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person....This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above by not having the Administrator avaliable during three inspection visits on 9/2, 10/13 and 11/13/2025. This poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Administrator shall attend 1 hour of training regarding Administrator Qualifications and Duties with a Qualified Consultant copy of training shall be submitted to LPA. Administrator shall also submit a document indicating they understand licensing regulations regarding Administrator Qualifications and Duties. (Please note this is 1 hour of training)

Allegation investigated: Staff prevented resident in care from conducting a confidential call at the facility.

On 10/13/2025, Licensing Program Analysts (LPAs) Lorena Casillas and Huma Rahimi conducted an unannounced subsequent 10-day complaint visit to the facility to investigate the above allegations. LPAs were greeted and granted access to the facility by staff. LPAs met with Licensee Mari Akmakchyan who arrived shortly after, and LPAs explained the reason for the visit. Entrance interview conducted. On 08/28/2025, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation mentioned above. On 09/02/2023, LPA Rahimi initiated the complaint visit. LPA Rahimi conducted a tour of the facility and obtained copies of pertinent information. LPA Rahimi also conducted and interviewed with the Licensee and residents. LPA Casillas reviewed documents collected by LPA Rahimi and interviews conducted by LPA Rahimi. Continued on LIC9099-C Unsubstantiated On 10/13/25 At approximately 11:30 am, LPA Casillas requested copies of resident and staff rosters. At 12:15 pm, LPAs conducted a physical plant tour to ensure the health and safety of the residents are protected. At approximately 12:45 pm LPAs conducted file reviews of resident records. Allegation: Staff prevented resident in care from conducting a confidential call at the facility. It is alleged that staff prevented resident in care from conducting a confidential call at the facility. It is reported that during Resident #1 (R1)’s Telehealth appointment Licensee took over the appointment interjecting themselves, not allowing provider and R1 to converse with each other. It is also reported that when provider was offering R1 some services that Licensee again interjected themselves and was being sarcastic making comments to ridicule R1. During LPA Rahimi’s previous interviews it was discovered that the incident did not happen as it was reported and instead R1 stated that the provider was the rude one and that R1 wanted Licensee present during their appointment as Licensee assists R1 with these matters. LPA Rahimi interviewed Licensee who also reiterated that R1 wanted Licensee present during the appointment and that Licensee was in fact defending and encouraging R1 to seek the services R1 needs. LPA Rahimi interviewed three (3) out of three (3) residents present at the facility and they also stated that they have no concerns with staff not allowing confidentiality or privacy. Therefore, based on interviews and observations this allegation is deemed unsubstantiated at this time. No citation issued. Exit interview conducted and copy of report provided to Licensee.the state’s words, verbatim · CDSS document, Oct 13, 2025 · control 31-AS-20250828113316

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Huma Rahimi and Lorena Casillas conducted a subsequent unannounced visit to the facility in conjunction with complaint control #31-AS-20250828113316. Upon arrival, LPAs met with Staff #1 (S1), who granted access to the facility. The Licensee was contacted by the LPAs and were informed that the Administrator would be unable to join LPAs due to an appointment. LPAs explained the purpose of the visit and the Licensee arrived shortly after at 11:15 AM. On September 2, 2025, LPA Rahimi conducted an initial complaint visit and was informed that approximately the last week of June 2025, a former staff member allegedly restrained Resident #2 (R2) which caused discomfort and pain in the presence of a witness . LPA interviewed the witness, who confirmed that the former staff member did, in fact, restrain R2, causing R2 to experience pain. LPA was informed that it was reported to the Licensee and the staff member was immediately fired and is no longer working at the facility. However, no incident report was submitted to the Community Care Licensing Department (CCLD). LPA reviewed all incident reports submitted through CCLD internal system and did not observe an incident report regarding this particular incident with R2. In addition, during today's visit, the Licensee admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Licensee that all staff members are mandated reporters and they are all responsible for reporting. LPAs informed the Licensee to submit an incident report that occurred on or before : Last week of June, 2025. Continue on LIC 809C During today’s physical plant tour, LPAs observed one (1) resident to be bedridden and three (3) residents to be non ambulatory in bedrooms #1 and #3 respectively, despite the facility being licensed for six (6) ambulatory residents only. LPAs reviewed resident records and observed that R2 is bedridden and three (3) out of six (6) residents are non-ambulatory and two (2) out six (6) resident are ambulatory. LPAs spoke to the Licensee and explained the importance of abiding by fire clearance. LPAs also explained that the bedridden and non ambulatory residents would need to be relocated and are not allowed to return until the fire clearance is approved. Furthermore, it was explained to the licensee that only residents cleared on fire clearance are allowed. Moreover, LPAs were informed that Staff #2 (S2) has been working at this facility providing direct care and supervision for two (2) days. However, LPAs reviewed the online Guardian website as well as LIS and did not observe S2 being associated with the facility. LPAs also explained to the Licensee the importance of associating staff to the facility. Based on interviews, observations and records reviews citations and civil penalties will be issued. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Oct 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Oct 14, 2025

Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...(2) Bedridden persons... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by accepting a bedridden and non-ambulatory residents without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2025

Plan of correction: Licensee agreed to re-locate resident with bedridden and non-ambulatory status until the fire clearance is obtained and approved. Licensee will provide re-location information via e-mail by the POC due date (10/14/2025). Civil penalty will be assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Oct 14, 2025

7355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline. Based on interview and record review, the licensee did not comply with the section cited above by hiring S2 on 10/12/2025 without association, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2025

Plan of correction: Licensee agreed to associate S2 to the facility. The Licensee will submit the proof of correction to LPA by POC due date. Civil penalty assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Oct 20, 2025

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPAs, the licensee did not comply with the section cited above by failing to notify CCLD regarding the staff restraining R2 in June, 2025, which caused discomfort and pain to R2. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R2's incident report shall be submitted to LPA by POC date.

Type of visit: Required - 1 Year

At 12:30 PM, Licensing Program Analysts (LPAs), Huma Rahimi, and Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted by the staff, Mari Akmakchyan, who granted access to the facility. LPAs explained the reason for the visit. This facility is licensed for the capacity of six (6) Ambulatory residents. Upon arrival, Mrs. Akmakchyan informed LPAs that the facility currently has five (5) residents, of which two (2) are bedridden and three (3) are ambulatory. LPAs were also informed that none of the residents are on Hospice. At approximately, 12:35 PM, LPAs conducted a tour of the facility, and the following was observed: Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. No obstructions observed throughout the facility. The facility license was not posted and or available for review. Kitchen: LPAs observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. At 10:15am, LPAs observed resident medications/injectable in the refrigerator unlocked. All knives and other sharps were observed locked in the kitchen drawer. LPAs observed all other medication locked in the kitchen cabinet. There is a fire extinguisher by the kitchen that was last purchased on 10/1/2024. Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms have appropriate bedding and linens. LPAs observed two (2) half rail beds in room #1 and room #2, without Physician order. Physician's order for half bed rails were not available upon request. Moreover, LPAs observed a television stand that was blocking the emergency exit door. Continue on LIC 809C Bathrooms: LPAs observed two (2) bathrooms for resident use and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPAs observed appropriate grab bar and resident's bathroom had non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. Outside areas: At approximately, 12:50 PM, LPAs toured the outside area of the facility. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Laundry: Laundry room is located outside and during the walk though, LPAs observed the room locked and inaccessible to residents in care. Resident Files: At 11:00am LPAs conducted resident and staff records review. The following was observed. two (2) out of five (5) resident files were incomplete. Files were missing Admission Agreement, Resident Preplacement, Appraisals/Reappraisal, List of personal property, ID Emergency Sheets, and Personal Rights. Please see LIC858 included with this report. Staff Files: The following was observed. The Administrator has not renewed her Administrators Certificate since 08-26-2020, and the facility is currently have no active Administrator on file. LPAs conducted review of Licensing Information System and did not observe Staff #1(S1) being associated with the facility. S1's fingerprints determination on a guardian was: " Not Eligible. Determination Closed." Medications review: At approximately, 3:00pm LPAs conducted a review of medication for residents in care. All records were observed to be complete and updated. Administrative: . LPAs collected a copy of Liability Insurance and LIC500. Deficiencies and civil penalty issued, see LIC809Ds. Exit interview conducted, appeal rights explained and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Mar 18, 2025

Type of visit: POC

An unannounced Case Management visit was conducted on this day by Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina. The purpose of this visit is to follow up on the Plan of Corrections (POCs) that were issued during an annual visit made on 04/23/2024. Entrance interview conducted with the Staff. LPA received previously issued deficiencies POCs. However, Section 87202(a)(2) for the Fire Clearance has not been corrected. Although LIC200 had been submitted to the Regional Office the Fire Clearance had not been yet approved. During todays visit, LPAs were informed that multiple connections were made with the Fire Inspector who advised that prior to Fire Clearance an approval from the Building and Safety is required. LPAs were also informed that the process is still on a pending status. Further notification/update will be submitted to LPA promptly. Also during today's visit, LPAs observed all four (4) out of four (4) residents to be Ambulatory. No deficiency cited during todays visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff was negligent while assisting resident(s) while transferring to/from bed.

At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi conducted an unannounced subsequent complaint visit to deliver final findings. LPAs met with the Administrator and explained the reason for the visit. During the initial visit conducted on 07/07/2023, LPA Panushkina requested resident and staff roster. At approximately 10:10am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. At 10:30am, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Hospital Discharge papers, etc., relevant to the investigation. Between 11:00am – 12:00pm, LPA conducted an interview with the Administrator, two (2) staff members and three (3) out of four (4) residents, who were able to communicate. Continue on LIC9099-C Substantiated Allegation: Staff was negligent while assisting resident(s) while transferring to/from bed. It was alleged that S1 handled R1 roughly while being transferred in and out of bed. It was also alleged that S1 dropped R1 on the floor on 3 separate occasions while trying to transfer in and out of the wheelchair. To investigate this allegation, LPA conducted an interview with the Administrator and four (4) residents. Only one (1) out of four (4) residents was present during R1’s stay at this facility. Although interview with one (1) out of four (4) residents revealed that the staff never handled R1 in a rough manner nor did any falls occur, interview with the Administrator confirmed that S1 was a little bit on a rough side and several times S1 was told about changing his/her manners. However, Administrator denied ever witnessing or hearing about R1’s incidents of falling. Based on the information received, this allegation is Substantiated. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report provided to the Administrator. Allegation: Staff did not keep resident(s) free from punishment, humiliation, intimidation, abuse or other acts of a punitive nature. It was alleged that S2 would yell and threaten to hit R1. To investigate this allegation, LPA conducted an interview with the Administrator, two (2) staff and three (3) out of four (4) residents, who were able to communicate. Interview with the Administrator revealed that S2 was an amazing caregiver and provided care to all residents with dignity and respect. Moreover, only one (1) out of four (4) residents was present during R1’s stay at this facility, who corroborated Administrator's statement. Interview with two new staff members revealed that all resident's personal rights are being respected. Lastly, three (3) out of four (4) residents interviewed expressed no concerns regarding the above allegation. Therefore, based on interviews this allegation is deemed Unsubstantiated at this time. Allegation: Staff did not provide adequate required incontinent care to resident(s). During the initial visit conducted on 07/07/23, LPA observed all residents wear clean clothes, groomed and well taken care of. Interview with the Administrator and two (2) staff members revealed that all residents are being changed every 2-3 hours or as needed. Three (3) out of four (4) residents interviewed expressed no concern regarding the above allegation. Therefore, based on LPA's observation and interviews conducted, this allegations is deemed Unsubstantiated. Exit interview conducted appeal rights explained and copy of this report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 31-AS-20230630161933

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 30, 2024

Personal Rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews conducted, licensee failed to comply with the section cited above by not providing a proper training to staff. S1 handled R1 in a rough manner, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Corrected before the initial visit. Licensee/Administrator informed LPA that S1 was fired as of March 2023.

Type of visit: Required - 1 Year

At 10:00 AM, Licensing Program Analysts (LPAs), Huma Rahimi, and Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by the staff, Mari Akmakchyan, who granted access to the facility. LPAs explained the reason for the visit. This facility is licensed for the capacity of six (6) Ambulatory and one (1) Hospice residents. Upon arrival, Mrs. Akmakchyan informed LPAs that the facility currently has six (6) residents, of which four (4) are Non-ambulatory and one (1) is Bedridden. LPAs were also informed that only one resident (1) is on Hospice. At approximately, 10:10am team conducted a tour of the facility, and the following was observed: Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. No obstructions observed throughout the facility. The facility license was not posted and or available for review. Kitchen: LPAs observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. At 10:15am, LPAs observed resident medications in a kitchen cabinet and Clorox along with other chemicals and detergents under the kitchen sink were kept unlocked and accessible to residents. Moreover, all knives and sharps in the kitchen drawer were kept unlocked and accessible to residents in care. There is a fire extinguisher by the kitchen that was last purchased on 05/25/2023. Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms have appropriate bedding and linens. LPAs observed two (2) half rail beds in room #1 and only one resident had a doctor's order. Moreover, LPAs observed residents bed was blocking the emergency exit Continue on LIC809-C sliding door. In room #2, LPAs observed one (1) full rail bed and room #3 had two half rail beds, without physician's order on file. and one (1) full bed rail bed in room #3. Physician's order for half/full bed rails were not available upon request. Outside areas: At approximately, 10:40am team toured the outside area of the facility. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Laundry: Laundry room is located outside and during the walk though, LPAs observed the room was kept unlocked and accessible to residents in care. Cleaning supplies were not locked. Resident Files: At 11:00am LPAs conducted resident and staff records review. The following was observed. Six (6) out of six (6) resident files were incomplete. Files were missing signatures and forms (such as Admission Agreement, Physician’s Report, Resident Preplacement, Appraisals/Reappraisal, List of personal property, ID Emergency Sheets, and Personal Rights. Resident appraisals that were in the file did not have services explained and were missing signatures from the resident, and or responsible party. Please see LIC858 included with this report. Staff Files: The following was observed. The Administrator has not renewed her Administrators Certificate since 08-26-2020. There are no completed personnel records for all 3 staff members which include the administrator. All three (3) staff files were missing First Aid Certificate and Mrs. Akmakchyan had required training on file. Medications review: At approximately, 12:30pm LPAs conducted a review of medication for residents in care. None of the six (6) residents had a completed centrally stored medication and destruction record. No First Aid Kit available for review. Administrative: Annual fees are past due. Last notice was mailed 01-03-2024 due by 03-18-2024. Amount of $742 is due immediately. Infection control plan is due immediately. Plans were due June 2022. LPAs collected a copy of Liability Insurance and LIC500. Deficiencies and civil penalty issued, see LIC809Ds. Exit interview conducted, appeal rights explained and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Apr 23, 2024

Type of visit: Case Management - Other

At 10:00am, Licensing Program Analysts (LPAs) Huma Rahimi, Angela Panushkina, and Perchui Milena Khurshudyan conducted a Case Management Visit. LPAs met with the Staff # 1, Mari Akmakchyan and explained the reason for the visit. During the visit, S1 informed LPAs that S2 started working at this facility on 01/08/2024. LPAs conducted review of Licensing Information System and did not observe S2's association to this facility. LPAs informed the S1 that all staff members must be fingerprint cleared and associated prior to employment. Moreover, Administrators' Certificate on file has been expired and the facility does not currently have a back up Administrator. LPAs observed that only three (3) out of five (5) residents facility files are missing documents/signatures (incomplete). The facility is not approved to retain any bedridden resident; however, LPAs observed R2 and R3 were in bed and review of their Physician's Report indicated that they are both bed bound. Moreover, LPAs were informed that both residents are receiving Hospice Care (facility is currently approved for one (1) hospice waiver only). No Hospice files for R2 and R3 were available upon request. Lastly, LPAs observed R2 and R3 had full bed rail and no Physicians order on file. LPAs observed that R1 is on a wheelchair. Facility License (Effective 03/18/2019) is APPROVED FOR CAPACITY OF 6 AMBULATORY; APPROVED FOR HOSPICE WAIVER FOR 1 HOSPICE RESIDENT. The facility also failed to submit an Incident and Death Report for R6 to the Community Care Licensing Division (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report / Death Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed Administrator that all staff members are mandated reporters and they are all responsible for reporting. Deficiency issued on LIC809-D Exit interview conducted, appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 24, 2024

Criminal record clearance: (e) All individuals subject to a criminal record review... (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by hiring one (1) staff member S2 on January 8th, 2024 without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee agreed to complete S2's fingerprints and associate the staff to the facility. Copy of proof will be submitted to LPA by POC date. Civil penalty assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a)(2) · Plan of correction due date: Jan 24, 2024

Fire Clearance: (a) All facilities shall maintain a fire clearance approved... Prior to accepting or retaining any of the following types of persons... (2) Bedridden persons This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by accepting two (2) bedridden residents (R2 and R3) without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee agreed to complete and submit LIC200 along with the facility sketch to Fire Department for a Bedridden and non-ambulatory approval by POC date. Bedridden plan of operation and proof will be submitted to LPA Civil penalty issued

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87406(g) · Plan of correction due date: Jan 30, 2024

Administrator Certification Requirements: (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Faciity's Administrator certificate had been expired since August 2020, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee agreed to renew the Administrator certificate and submit proof of enrolled classe to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Jan 30, 2024

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Three (3) resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee agreed to complete three (3) out of five (5) resident files.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jan 24, 2024

Postural Supports: Based on the individual pre-admission apprasial... Postural support maybe used udner the following condition: 3) A written order from the Physician indication... licensing agency shall be authorized to require... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above having two (2) full bed rail beds and two (2) half bed rail without a doctors approval, which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee agreed to obtain a doctor order for two (2) half bed rails and two (2) hospice full rails. Copy of proof will be submitted to LPA

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(a)(1) · Plan of correction due date: Jan 30, 2024

87632 Hospice Care Waiver: (a) In order accept or retain terminally ill residents... To obtain this waiver the licensee shall submit a written request for a waiver to the Department... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by addmiting two (2) hospice residents, when theh facility is only approved for one (1). This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee agreed to submit a hospice exception for one (1) resident. Proof of the exception letter will be emailed to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)A,B&D · Plan of correction due date: Jan 30, 2024

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the two (2) incidents that occured with R6, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copies of two (2) incidents, shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1,2) · Plan of correction due date: Jan 30, 2024

Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements... This requirement is not met as evidenced by: Based on interviews, the licensee failed to insure that the administrator had knowledge of licensing rules and regulations which poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Licensee agrees to follow proper guidelines for Administrator Qualifications. LPA discussed with the administrators section 87405. Licensee agrees to submit a written letter to CCL indicating that they have read the regulations, have full understanding