Amy's Paradise Home of Angels

Allegation investigated: Staff engaged in an inappropriate relationship with resident. Staff did not seek timely medical attention for resident.

Licensing Program Analyst (LPA) Trevor Byrne conducted a follow-up complaint visit for the above allegations. LPA arrived to the facility at 01:28 PM. LPA met with facility staff who contacted the facility Administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Facility representative Meri Tarposhyan (S2) arrived to the facility at 01:45 PM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a physical plant tour and delivered findings between 01:30 PM and 04:00 PM. The allegation of “Staff engaged in an inappropriate relationship with resident” alleges that facility staff #1 (S1) engaged in an inappropriate relationship with Resident #1 (R1) while R1 resided at the facility. On 05/30/2025, LPA interviewed S1, and during the interview S1, they confirmed that they and R1 were married at the facility. S1 provided LPA with a copy of the marriage certificate between them and R1 with an effective date of 11/01/2024. CONTINUED ON LIC 9099C. Substantiated Interviews with Witness #1 (W1) and Witness #2 (W2) revealed concerns that R1 was manipulated by the facility into marrying S1 for immigration or green card purposes. Interviews with R1 revealed that R1 did not feel pressured into marrying S1, and R1 denied any coercion from S1 or facility staff. Interviews with S1 and R1 revealed that they intended to go to the immigration office to obtain documents for S1, but no such visit took place due to issues in obtaining the required perquisite documentation. LPA reviewed R1’s medical documentation and facility file. R1 was determined by their physician to not have cognitive deficit, was able to make their own decisions, and was able to manage their own finances. Additionally, LPA observed R1 to be self-responsible and did not have a Power of Attorney (POA). On 03/18/2026, LPA interviewed S1 and R1. LPA was informed that as of 02/17/2026, S1 and R1 were legally separated. Based on interviews and record review there is sufficient evidence to support the allegation of “Staff engaged in an inappropriate relationship with resident.” Therefore, the allegation is deemed Substantiated at this time. The allegation of “Staff did not seek timely medical attention for resident” alleges that the facility did not seek timely medical attention for R1 following a medical emergency which occurred at the facility. Interviews with S1 revealed that on 05/14/2025, R1 suffered a medical emergency at the facility and required hospitalization. S1 stated that symptoms, including diarrhea, were first noticed the day prior (05/13/2025) and were monitored by S1. S1 stated that on 05/14/2025, they observed blood in R1’s stool. S1 reported observing the blood for approximately two (2) to three (3) hours before calling the Administrator and later emergency services to transport R1 to the hospital. LPA interviewed the Administrator who stated that R1 appeared fine on the morning of 05/14/2025, but around 12:00 PM R1’s blood pressure was observed by S1 to be rapidly dropping. Administrator stated that they received a follow-up call from S1 at approximately 05:00 PM informing them that R1 was not doing well. Administrator stated that an ambulance was called for R1 at approximately 06:00 PM and R1 was transported to the hospital for treatment. LPA reviewed the hospital paperwork from R1’s 05/14/2025 hospitalization. LPA observed that R1 was admitted to the hospital in critical condition with severe hyperkalemia (high potassium levels in blood) and later suffered cardiac arrest. Based on interviews, LPA observed a delay in seeking timely medical attention for R1 of more than twenty-four (24) hours from the initial onset of symptoms and six (6) hours of the presentation of severe symptoms. Based on interviews and record review there is sufficient evidence to support the allegation of “Staff did not seek timely medical attention for resident.” Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 29-AS-20250528153637

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Apr 10, 2026

87465 Incidental Medical and Dental Care (a) ...by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. 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 the facility did not seek timely medical attention for R1 following the presentation of symptoms of a medical emergency which posed an immediate health risk to clients in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator agreed to conduct training with all staff members of the facility covering the importance of noticing signs and symptoms of a medical emergency and seeking medical attention in a timely manner. Administrator agreed to submit proof of completed training to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 23, 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, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above as S1 entered into an inappropriate relationship with R1 through their marriage and subsequent divorce which posed a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator agreed to conduct a meeting with staff members of the facility covering what constitutes appropriate staff/resident relationship and what behaviors are acceptable for facility staff. Administrator agreed to submit proof of the meeting to CCLD no later than POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 01:28 PM. LPA met with facility staff member Emma Elazyan (S1) who contacted the facility Administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Facility representative Meri Tarposhyan (S2) arrived to the facility at 01:45 PM. Entrance interview was conducted and the reason for the visit was explained. Beginning at approximately 01:50 PM, the LPA, along with S2 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 had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed secured cabinets which contained knives and other sharp objects, resident medications, facility files, and an incomplete first aid kit which was missing a first aid manual. LPA informed S2 that a complete first aid kit shall be maintained and be readily available and shall include a current edition of a first aid manual. S2 expressed understanding and agreed to obtain a current first aid manual for the facility. LPA observed the kitchen to contain adequate emergency food supplies. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 09/24/2025. CONTINUED ON LIC 809C. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard of the facility. LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain an additional refrigerator which contained extra food items. LPA observed the side gate and front gate of the facility to be missing properly functioning auditory alarms. LPA informed S2 that an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates shall be present and functional. S2 expressed understanding and agreed to install working auditory alarms on both gates. COMMON AREAS: This included the living room, hallway, and dining area. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain a television and activities for resident use. LPA observed a hallway closet which contained extra linens and care supplies. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contained a dining table with adequate seating for resident use. The facility’s fire and carbon monoxide alarms were tested at 03:04 PM and were functional at the time of the test. BEDROOMS: There are four (4) bedrooms in the facility; two (2) are a dual occupancy rooms and two (2) are single occupancy rooms. LPA and S2 toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed bedroom #1’s closet doors to be in disrepair. LPA notified S2 who stated that a repairman was coming later today (04/09/2026) to perform repairs to the doors. LPA observed unsecured paints located in the closet of bedroom #2. LPA notified S2 who secured the items at the time of the visit. BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. LPA observed the shared resident bathroom’s tub to be consistently leaking water from the faucet. LPA notified S2 who agreed to schedule a repairman to perform repairs to the tub. Grab bars were observed in all resident showers and near the shared resident toilet, all were properly secured. CONTINUED ON LIC 809C. BATHROOMS CONT: LPA observed the private resident bathroom’s toilet to be missing grab bars. LPA interviewed Resident #1 (R1) who resided in the bedroom that was attached to the private bathroom. R1 confirmed that they do not utilize the private bathroom and instead prefer to use the shared resident bathroom. LPA informed S2 that grab bars shall be maintained for each toilet; bathtub and shower used by residents. Since no resident utilizes the private bathroom this is considered a technical violation and no deficiency is being issued. LPA informed S2 that if R1 or any future resident utilizes the private bathroom appropriate grab bars will need to be installed near the toilet. S2 expressed understanding and agreed to comply with this regulation. Additionally, LPA observed an unsecured bottle of Clorox air freshener located in the private bathroom. LPA notified S2 who secured the bottle at the time of the visit. The water temperature was measured to be between 116.1 and 118.0 degrees Fahrenheit, which is in compliance with regulation. 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; the facility’s last emergency disaster drill was conducted on 01/25/2026. The facility’s emergency disaster plan is up to date but contained inaccurate information on the storage location of emergency supplies. LPA notified S2 who agreed to complete an update to the facility’s emergency disaster plan. The emergency disaster plan and the infection control plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. One (1) staff interview was conducted with the assistance of S2 acting as a translator. The staff member interviewed was knowledgeable on 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, emergency disaster plan, and current liability insurance. The facility Administrator was unable to come to the facility to sign this report but has designated S2 to sign on their behalf. This report was read to the Administrator via telephone call. 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, Apr 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(8)(A) · Plan of correction due date: Apr 23, 2026

87465 Incidental Medical and Dental Care (a) ... by compliance with the following: (8) ...The kit...shall contain at least the following: (A) A current edition of a first aid manual... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the facility did not have a current edition of a first aid manual which poses a potential health or safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator agreed to obtain a first aid manual and to send proof of the manual at the facility to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(d) · Plan of correction due date: Apr 23, 2026

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the side and front gates were missing properly functioning auditory alarms which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator agreed to send proof of appropriately installed and functioning auditory alarms on the identified gates to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(c) · Plan of correction due date: Apr 23, 2026

87309 Storage Space and Access (c) ... the licensee shall...ensure that ... other potentially toxic substances... are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as a Clorox spray air freshener was unsecured and paints were stored in a resident's room who was at risk if allowed access to toxic substances which posed a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: S2 secured the items at the time of the visit. Administrator agreed to conduct training with all staff on the importance of securing toxic substances. Administrator agreed to submit proof of the completed training to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Apr 23, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the closet doors in bedroom #1 and the shared tub were in disrepair which poses a potential safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator agreed to complete repairs to the identified items and to send proof of the completed repairs to CCLD no later than POC due date.

Allegation investigated: Staff mismanage residents' medication.

Licensing Program Analyst (LPA) Trevor Byrne conducted a complaint visit for the above allegation. LPA arrived to the facility at 09:44 AM. LPA met with facility staff member Emma Elazyan (S1) who contacted the facility administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Facility representative Meri Tarposhyan (S2) arrived to the facility at approximately 11:50 AM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a brief physical plant tour, a medication and file review for six (6) residents, obtained copies of pertinent documentation, and conducted interviews with S1, S2, and one (1) resident between 09:55 AM and 02:00 PM. Continued on LIC 9099C. Substantiated The allegation of “Staff mismanage residents' medication.” Alleges that facility staff mismanage resident’s medications and that facility staff inappropriately administer sleeping pills to residents. LPA conducted a medication review for six (6) residents. LPA interviewed Staff #1(S1) and Staff #2 (S2). Both staff members denied administering any medications not prescribed by a physician, including sleeping aids, to residents. LPA observed two (2) resident’s Centrally stored medication and destruction record sheets (CSMDRs) to contain inaccurate records of the resident’s prescribed medications. Additionally, during the audit of resident’s medications LPA observed a total of twenty three (23) medications across six (6) residents to have errors in the medication count. LPA and S2 observed the CSMDRs for six (6) residents and confirmed that the amount of medications remaining in the bottles did not match the amount of medications that should be left based on the recorded start date and medication administration instructions. The resident interviewed did not have concerns with the administration of medications at the facility. LPA did not observe evidence of unprescribed sleeping pills being administered to residents but did observe evidence of medication mismanagement. Based on interviews and record review there is sufficient evidence to support the allegation of “Staff mismanage residents' medication.” Therefore the allegation is deemed Substantiated at this time. The facility Administrator was unable to come to the facility to sign this report but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted and copy of the report was issued and appeal rights providedthe state’s words, verbatim · CDSS document, Mar 18, 2026 · control 29-AS-20260311081619

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 19, 2026

87465 Incidental Medical and Dental Care (a) ... 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 observation, record review and interview the licensee did not comply with the section cited above as twenty three medications across six residents had errors in the medication count which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Administrator agreed to conduct an immediate training with all staff handling resident medications covering best practices for medication administration and to submit proof of the completed training to CCLD 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 09:44 AM. LPA met with facility staff member Emma Elazyan (S1) who contacted the facility administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Facility representative Meri Tarposhyan (S2) arrived to the facility at approximately 11:50 AM. Entrance interview was conducted and the reason for the visit was explained. The following was observed: MEDICATION REVIEW: Medication review began at 09:55 AM. Medications for six (6) of six (6) residents were observed. LPA observed Resident #1’s (R1) medications to be improperly documented on their centrally stored medication and destruction record sheet (CSMDR). LPA informed S2 who stated that the medications arrived at the facility at approximately 08:00 PM the previous night (03/17/2026) and had not yet been documented on the CSMDR. Additionally, LPA observed one (1) medication from Resident #2 (R2) to not be logged appropriately on their CSMDR. During medication review LPA observed a total of twenty three (23) medications across all six (6) residents to have errors in the medication count. LPA and S2 observed the CSMDRs for all six (6) residents and confirmed that the amount of medications remaining in the bottles did not match the amount of medications that should be left based on the recorded start date and medication administration instructions. S2 was unable to provide LPA with a justification as to why the medication count was incorrect. This deficiency was cited under a complaint report for this facility. No deficiency for this violation is being generated under this report. Continued on LIC 809C. RECORD REVIEW: Record review began at 11:50 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. One (1) staff file was not located at the facility for LPA's review. LPA informed S2 that all personnel records shall be maintained at the facility for review. Four (4) staff files were observed to contain expired 1st aid certifications. Six (6) resident files were reviewed. One (1) resident file was observed to contain a blank Appraisal Needs and Services (ANS) plan, and two (2) resident files contained ANS that were created more than twelve (12) months prior. LPA informed S2 that appraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition. LPA observed two (2) resident admission agreements to be missing the rate for all basic services which the facility is required to provide. LPA observed Resident #3 (R3)’s resident file to contain a physician’s report dated 11/05/2024. LPA informed S2 and the Administrator that Community Care Licensing Division (CCLD) is requesting an updated physician’s report for R3 due to a changes in the condition of R3 since the report was created. Due to time constraints LPA will return at a later date to conduct a physical plant tour, a review of the infection control plan and emergency disaster plan, interviews with residents and staff, and to collect copies of pertinent documents. The facility Administrator was unable to come to the facility to sign this report but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were 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, Mar 18, 2026

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted unannounced case management deficiencies visit at the facility today. LPA arrived to the facility at 10:15 AM. LPA met with the facility staff, staff #1 (S1) who contacted the facility Administrator Emma Avetisyan via telephone call. The Administrator arrived to the facility at approximately 12:30 PM. Entrance interview conducted and the reason for the visit was explained. During today’s visit, the LPA conducted a physical plant tour to ensure there are no health and safety hazards, collected copies of pertinent documents, conducted a medication audit for one (1) resident, and conducted interviews with the Administrator, one (1) staff member, one (1)resident, and one (1) witness between 10:20 AM and 02:00 PM During the physical plant tour LPA observed the flooring near the exit located in the kitchen to be bubbling up, held together with tape, and in disrepair. Additionally, LPA observed the closet door located in bedroom # 2 to be detached from the railing and in disrepair. LPA observed a light switch cover in the shared resident bathroom to be broken and had sharp exposed plastic. LPA informed the Administrator of the items that were in disrepair and the Administrator agreed to perform the needed repairs to the identified items. During an interview with S1 and the Administrator LPA was informed that resident #1 (R1) was recently hospitalized after a medical incident. LPA reviewed the facility file and their inbox and did not observe an incident report submitted for the hospitalization of R1. LPA informed the Administrator that incidents must be reported to Community Care Licensing Division no later than seven days following the occurrence of the incident. The Administrator expressed understanding and submitted a report for the incident at the time of the inspection. Continued on LIC 809C. During medication review LPA observed R1's medications. LPA observed one (1) medication to not be listed on R1's centrally stored medication and destruction record sheet (CSMDR). LPA informed the Administrator of the discrepancy. The Administrator agreed to conduct a medication audit and submit an accurate CSMDR for R1 to CCLD. During file review LPA observed the resident file for resident #2 (R2). LPA observed this resident’s physician report to identify the resident as “Ambulatory” and “Able to feed self”. During the visit LPA observed R2 to be utilizing a wheelchair and being fed by S1. LPA asked the Administrator about the condition of R2. The Administrator confirmed that R2 was a Non-Ambulatory resident based on their physical condition and mental diagnosis. The Administrator stated that this is a recent change of condition, and the facility had not yet obtained an updated physician report for the change in condition. LPA informed the Administrator that the facility’s fire clearance does not allow them to accept or retain Non-Ambulatory residents. LPA informed the Administrator that this is a violation of their fire clearance and poses an immediate safety risk to clients in care. LPA informed the Administrator that this is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (05/30/2025). The Administrator expressed understanding and confirmed that they will contact the local fire department and notify them that they have a Non-Ambulatory resident. Additionally, the Administrator confirmed that the resident would be relocated to a licensed facility that has an appropriate fire clearance to care for Non-Ambulatory residents. During the file review for R2 LPA observed R2’s physician’s report to be missing a negative TB test. LPA asked the Administrator if they were able to provide proof of a negative TB test for the identified resident. The Administrator stated that the physician’s report was transferred from another facility and the facility had not yet obtained an updated physician report for R2. LPA informed the Administrator that they were recently cited for a violation of CCR 87458(c)(1)(A) on 02/20/2025. LPA informed the Administrator that this is a repeat violation of the same regulation within a 12-month period and a civil penalty in the amount of $250 will be assessed on today’s date (05/30/2025) for a repeat violation. The Administrator was unavailable to sign this report but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalties 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 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: May 31, 2025

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement is not met as evidenced by: Based on observation and file review the Licensee did not comply with the section cited above as one resident was observed to be non-ambulatory for which the facility does not have an approved fire clearance which poses an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: The Administrator stated that they will contact the local fire department and notify them that they have a Non-Ambulatory resident. Additionally, the Administrator confirmed that the resident would be issued an eviction notice and be relocated to an appropriate facility. Licensee will submit their plan on how they will evacuate the identified resident safely from the facility in the event of a fire or emergency. Licensee will submit proof of corrections no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(c)(1)(A) · Plan of correction due date: Jun 13, 2025

87458 Medical Assessment (c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating...all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Based on file review the Licensee did not comply with the section cited above as one resident file was observed to be missing proof of a negative TB test which poses an potential health risk to clients in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: The Licensee will obtain an updated physician report for R2 confirming a negative TB test. The Licensee may also satisfy this POC via the eviction of R2 due to the fire clearance violation mentioned above. Licensee will submit proof of corrections no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 13, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence... This requirement is not met as evidenced by: Based on file review and interview the Licensee did not comply with the section cited above as incident reports for R1's hospitalization and R2's change of condition were not submitted to CCLD which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Administrator submitted R1's incident report at the time of the visit. Licensee will submit an incident report for R2 and will submit a statement of understanding confirming that they understand the importance of submitting reports in a timely manner. Licensee will submit these items no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(b) · Plan of correction due date: Jun 13, 2025

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition... This requirement is not met as evidenced by: Based on file review and observation the Licensee did not comply with the section cited above as R2 had a change of condition that was not reflected on their physician report which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: The Licensee will obtain an updated physician report for R2. The Licensee may also satisfy this POC via the eviction of R2 due to the fire clearance violation. Licensee will submit proof of corrections no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 13, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation the Licensee did not comply with the section cited above as the flooring in the kitchen near the exit, the closet door in room # 2, and the light switch cover in the shared resident bathroom were in disrepair which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee will submit proof of completed repairs for the identified items. Licensee will submit proof no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Jun 13, 2025

87465 Incidental Medical and Dental Care (h) The following... shall apply... (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as one medication prescribed to R1 was not logged on R1's CSMDR which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: The Administrator agreed to conduct a medication audit and submit an accurate CSMDR for R1 to CCLD 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 09:03 AM. LPA met with facility staff member Emma Elazyan (S1) who contacted the facility administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:10 AM, the LPA, along with S1 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. LPA observed a secured cabinet to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications and a first aid kit. One (1) additional secured cabinet was observed to contain facility files. LPA observed a cabinet to contain adequate emergency food supplies. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 02/26/2024. COMMON AREAS: This includes the living room, hallway, and dining area. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain a television and activities for resident use. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. LPA observed a hallway closet to contain extra linens. The facility’s fire and carbon monoxide alarms were tested at 09:47 AM. At 09:48 AM LPA observed the facility’s carbon monoxide alarm to be non-functional. All exits in the facility were observed to contain functioning auditory alarms. Continued on LIC 809C. BEDROOMS: There are four (4) bedrooms in the facility; two (2) are a dual occupancy rooms and two (2) are single occupancy rooms. LPA and S1 toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #2’s window was observed to be missing a window screen. Bedroom #1’s window screen was observed to be seated improperly in the frame which left an opening in the corner of the frame. BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and 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 between 138.2 and 140.4 degrees Fahrenheit, which outside of the range required by regulation. The private resident’s bathroom window screen was observed to be seated improperly in the frame which left an opening in the corner of the frame. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain two (2) additional refrigerators containing extra food items. RECORD REVIEW: Record review began at 10:00 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. Four (4) staff files were reviewed. One (1) staff file was observed to be missing the required LIC 508 Out-of-state disclosure sheet. One (1) staff file was observed to be missing the LIC 503 Health screening report – facility personnel and a negative TB test. Six (6) resident files were reviewed. One (1) resident file was observed to be missing a negative Tuberculosis (TB) test. MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for six (6) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. Continued on LIC 809C. 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 01/14/2025. The facility’s emergency disaster plan is adequate. The emergency disaster plan was last reviewed/updated by the Administrator on 06/22/2021 which is outside of the required annual timeframe. The infection control plan is reviewed/updated annually by the facility’s administrator. INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. One (1) staff interview was conducted. The staff member interviewed was knowledgeable on 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 and resident roster. The facility was unable to provide a copy of valid liability insurance at the time of the inspection. The facility Administrator was unable to come to the facility to sign this report but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. 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, Feb 20, 2025

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct an annual inspection- continuation visit. The LPA was greeted by staff. Staff contacted the Administrator by phone. The LPA communicated with the administrator via phone, and informed them of the visit. RECORDS: At 12:16 p.m. the Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Records were in order. MEDICATIONS: Medications review began at 2:10 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report Facility staff representative signed today's report. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 5, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. LPA Urena was greeted by staff and explained the reason for the visit. Staff called administrator Emma Avetisyan on the phone, and the LPA explained the reason for the visit. LPA communicated with Administrator via cell phone. LPA Urena and staff conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 70 degrees. The LPA observed required postings throughout the common space. KITCHEN: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. The freezer and refrigerator are stocked with a variety of foods. The emergency food supply is adequate for six residents and two staff. The laundry room is equipped with a functioning washer and dryer. The room was locked at the time of inspection. One fire extinguishers were fully charged and were last serviced/purchased on 02/26/2024 BEDROOMS: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Bedroom #1 had one bed without linens or blankets. The other linens are clean and in good condition. Extra linens are found stored in the linen closet located between bedrooms #1 and #2. Continues on LIC 9099C... BATHROOMS: Bathroom was clean, shower area was in clean condition with grab bars, and a non-skid mat available. Hand washing sign was displayed, and sufficient amounts of soap and paper products in the bathroom. OUTDOOR AREA: Backyard has a covered outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. The side gate is unlocked. The gate has an alarm system. Several items(empty food plastic canisters, plastic bags, monitor, non-operational refrigerator, and metal long pieces were observed, which need to be removed from the seating outdoor/backyard area. RECORDS: Records review began at 11:00 a.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Five out of six residents' physicians reports(LIC 602) TB Test section 6. was incomplete and did not have date test give, read, type of TB test. Six out of six Personal Property and Valuables form(LIC 621) first page was not filled out. Five out of six residents' records were missing residents' or/residents' representative signatures on different required forms: Admission Agreements, Personal Rights, etc. Two out of six residents files did not have physician's orders for hospice/home health care. The LPA reviewed the following documents: - LIC9020 Client Roster - Liability Insurance Due to time constraints, the LPA will conduct a continuation inspection at a later date. Facility staff representative signed today's report. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 28, 2024