California State Health Group

Type of visit: Case Management - Legal/Non-compliance

At 08:30 AM, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda, conducted a Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. LPA met administrator, Andranik Kapikyan, and explained the reason for the visit. On April 7, 2026, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional Office. As a result of that NCC, the facility was placed on a two-year compliance plan. The purpose of today’s visit is to conduct thorough inspection to ensure compliance. LPA conducted a physical plant tour to ensure the health and safety of the clients and that the physical plant was in compliance with CA Title 22 Regulations at 1:23PM. At approximately 2:05 PM, LPA requested staff and resident records. LPA was informed that the facility currently has six (6) residents and two (2) staff members. During today's visit LPA observed two (2) staff members on duty. LPA also checked the Licensing Information System (LIS) and observed that staff members/ Caregivers are associated with this facility and the fingerprints are cleared. LPA interviewed all residents, and all residents confirmed they feel happy, they love the facility, and have no concerns regarding food, staff and/or the care they receive in the facility. Resident Files: At 10:27 PM LPA conducted resident and staff records review. The following was observed. Six (6) out of six (6) residents’ files were updated and complete. All required forms were present. Staff Files: The Administrator stated that the facility currently has two (2) staff members. LPA observed all files were complete and updated. Exit Interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 24, 2026

Allegation investigated: Resident developed multiple unstageable pressure injuries due to neglect.

Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Michael Cava conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation. LPAs met with staff, Muchengei Mangwende (S3), and explained the reason for visit. The Regional Office received the complaint on 09.01. 2025. The complaint was referred to the Investigations Branch and accepted the same day. LPA conducted a health and safety visit on September 3, 2025, at 4:00 PM, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, staff roster (LIC 500), resident roster (LIC 9020), needs and service plan, and relevant documents to the investigation. Between 3:10 PM – 3:30 PM, LPA interviewed the administrator (S1) and one (1) staff (S2) who are in the facility and six (6) out of six (6) residents. On 09.05.2025 and 10/8/25, Investigator Laura Garcia (IB) conducted interviews with staff and residents from around 2:30p.m. to 4:00p.m. Continue to LIC 9099-C Unsubstantiated It was alleged that Resident #1 (R1) had multiple unstageable pressure injuries due to neglect while residing at the facility. Interviews with staff indicated that R1 had no pressure injuries while residing at the facility. Interview with residents revealed that they are happy with the staff and provides proper care. All of the residents stated that they currently have no issues with neglect and that staff provide proper care and supervision. Based on document reviewed, it was revealed that R1 was admitted to the facility on 7.15.2025. R1 resided at facility until end of July 29, 2025. Interview conducted by IB investigator revealed R1’s responsible party removed R1 from the facility and moved R1 to an unknown location on 7/29/25. R1 was hospitalized on 8/19/25, when unstageable pressure injuries were discovered. R1’s physician’s report notes no history of skin condition and was not receiving home health services. There were no records indicating that R1 was receiving care for pressure injuries during R1’s stay at the facility. Therefore, based on interviews and record review and due to lack of supporting evidence, the allegation is unsubstantiated at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 31-AS-20250901225658

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. At 10:00 AM Andarik Kapikyan who is the administrator met with LPA, explained the reason for the visit. At 10:45 AM, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 11:00 AM the smoke alarms were tested and are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 12.17.2024. During the visit the facility is at 71 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; one (1) bedridden for bedroom #2. Hospice waiver for six (6). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen below the sink. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1 and bedroom #2 is private, but bedroom #3 and bedroom #4 are shared and is used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C Bathrooms: There are two (2) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 107.6 degrees Fahrenheit for bathroom #1 located in the hallway beside bedroom #2. Bathroom #2 is inside bathroom #1. There was enough clean linen available in the cabinets in the laundry room. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPAs observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool it is fence up and lock. The garage is detached and is converted into an office. Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located outside the patio. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Continue to LIC 809-C Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed resident's files for current appraisal. Planned activities are offered. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Administrator qualification.

Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda, Leizl DeLa Cerra, and Nadia Shahbazian conducted an subsequent complaint visit to the facility to investigate the above allegations. LPAs met with designee staff member, Isiah Phiri (S2) and was advised about the visit. Staff called administrator, Andranik Kapikyan, arrived at 9:35 AM; and was advised the reason of the visit. An entrance interview was conducted. Today's investigation involved interviews with the administrator and staff. LPAs also conducted a physical plant inspection of the facility at 9:24 AM to ensure the health and safety of the residents and a review of records. At 11 AM on 11.7.2024, LPA Ngo-Castaneda requested the resident and staff roster. During the investigation, interviews and record reviews were made. Continue to LIC 9099-C Unsubstantiated Between 10:15 and 10:45 AM, LPAs interviewed the staff and four (4) out of five (5) residents. Allegation #1: Administrator qualification It was specifically purported that the facility administrator deducted a portion of salary for staff #1(S1) and gave it to staff #2(S2) to resolve an agreement regarding an employee placement fee between the two employees. LPA conducted a facility file review for hiring practices. There is no employee hiring and or placement fee policy indicated in the plan of operation. LPA requested check issued by administrator and dated 06.2024 and 08.2024 signed by Administrator. The check shows that staff (S1) was paid $500 less than their normal pay. On 1.27.2025, LPA requested staff payroll ledger for review, however, was unsuccessful in obtaining the information. Interview with S2 indicated that there was an agreement with S1 that $1500 was to be paid to S2 as a staff placement fee. An interview with the administrator revealed that they were aware of the issue the staff was dealing with and did not get involved. The Administrator stated S1 had a salary deduction for the period of dates because they took a few days off from work. Therefore, based on interviews and review of documentation presented there is insufficient information to support this allegation. The allegation Administrator qualification is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 27, 2025 · control 31-AS-20240904133101

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. At 9:22 AM Andarik Kapikyan who is the administrator met with LPA, explained the reason for the visit. At 9:24 AM, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 12.17.2024. During the visit the facility is at 72 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents. Hospice waiver for six (6). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen below the sink. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1 and bedroom #2 is private, but bedroom #3 and bedroom #4 are shared and is used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C Bathrooms: There are two (2) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit for bathroom #1 located in the hallway beside bedroom #2. Bathroom #2 is inside bedroom #3. There was enough clean linen available in the cabinets in the laundry room. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPAs observed common areas to be very clean and tidy. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool it is fence up and lock. The garage is detached and is converted into an office. Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located outside the patio. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Continue to LIC 809-C Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisal. Planned activities are offered. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, Jan 27, 2025

Allegation investigated: Staff is buying alcohol for residents. Personnel qualification to dispense medication.

Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Huma Rahimi conducted an subsequent complaint visit to the facility to investigate the above allegations. LPA met with designee staff member (Isiah Phiri) and was advised about the visit. Staff called administrator and Andranik Kapikyan arrived at 10AM; and advised the reason of the visit. An entrance interview was conducted. Today's investigation involved interviews with the administrator, staff, and residents. LPA also conducted a physical plant inspection of the facility at 9:40 AM to ensure the health and safety of the residents and a review of records. At 11AM, LPA requested the resident and staff roster. During the investigation, interviews and record reviews were made. Continue to LIC 9099-C Unsubstantiated At 11AM LPA requested copies of pertinent information which include facility program and training documents relevant to the investigation. Between 10Am-11AM LPA interviewed the administrator, staff, and five (5) out of five (5) residents. Allegation #1: Staff is buying alcohol for residents. Administrator and staff interviews reveal that this facility is an Residential Care Facility for the Elderly (RCFE) and residents are allowed to go out in the community by themselves. It was alleged that staff (S2) would purchase alcohol for residents in care at the facility. During the interview it was revealed that staff always make sure that this is a safe and healthy environment for all clients, and drinking would be in moderation. Administrator and staff indicated that they have not received any complaint about other residents consuming alcohol. Interviews with administrator, staff and residents indicated that alcohol is allowed in the facility and have no concerns. Information revealed that staff did not provide alcohol to clients and staff ensured a safe and healthy environment for clients. Based on observation and interviews, there is insufficient information to support this allegation. Thus, this allegation is deemed UNSUBSTANTIATED at this time. Allegation #2: Personnel qualification to dispense medication. It was alleged that S1 was not comfortable distributing medication to the residents without proper training. Interview with administrator on 11.7.2024 revealed that before on boarding staff, they always need to undergo proper training in order to care and treats residents in care. Records review reveal current training on file for S1. On 9.10.2024 interview with five (5) out of six (6) residents reveal S1 to be pleasant, informative, professional, and helpful when distributing medication. Based on interviews and record review during this visits there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. Copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 31-AS-20240904133101

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff sleeping in common room. Facility is in disrepair.

Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Gina Saucedo conducted an initial complaint visit to the facility to investigate the above allegations. LPA met with designee staff member (S1), Isiah Phiri and was advised about the visit. Administrator was not available; staff called administrator and advised the reason of the visit over the phone. An entrance interview was conducted. Today's investigation involved interviews with the staff and residents. LPA conducted a physical plant inspection of the facility at 10 AM to ensure the health and safety of the residents. At 10:10AM, LPA requested the resident and staff roster, reports could not be produce. Administrator and staff was not available to show records to LPA. A case management will be cited. During the investigation staff and residents interviews were made. Continue to LIC 9099-C Substantiated Between 10:15-10:45 AM LPAs interviewed the staff, and six (6) out of six (6) residents. Allegation #1: Staff sleeping in common room. It was alleged that staff are sleeping in the living room common area. To investigate this allegation, at 10 AM, LPAs conducted a physical plant tour. LPAs did not observe any beds in the living room or other common areas, but did saw a couch in the living room. Between 10:15AM-10:45AM, staff and residents interviews were initiated. Interviews from three (3) out of six (6) residents revealed that staff S1 was sleeping in the living room. Based on observation and interviews, there is sufficient information to support this allegation. Thus, this allegation is deemed SUBSTANTIATED at this time. Allegation #2: Facility is in disrepair. Facility is in disrepair. It is being alleged that the tap water in the kitchen is not functioning and the bathroom in the hallway does not have a toilet seat, which could pose a health and wellness hazard. During the interview, it was confirmed that five (5) out of six (6) residents confirmed that they have not proper working tap working in the kitchen. During the interview, it was confirmed that the a toilet seat was not available for a month. During LPAs physical tour tap water in the kitchen was not working. Bathroom toilet seat eventually was available. Based on observation and interviews, there is sufficient information to support this allegation. Thus, this allegation is deemed SUBSTANTIATED at this time. Deficiencies were issued and recorded on LIC 9099-D. Exit interview conducted. Report signed and delivered. Appeal rights delivered. Staff interviews reveal that this facility is an Residential Care Facility for the Elderly (RCFE) and residents are allowed to go out in the community by themselves. It was alleged that staff (S1) would purchase alcohol for residents in care at the facility. During the interview it was revealed that staff always make sure that this is a safe and healthy environment for all clients, and drinking would be in moderation. Interviews with residents indicated that alcohol is allowed in the facility and other residents have not seen staff purchasing alcohol for the residents. Information revealed that staff did not provide alcohol to clients and staff ensured a safe and healthy environment for clients. No alcohol was seen at the facility. Based on observation and interviews, there is insufficient information to support this allegation. Thus, this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of this report is given to designee.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 31-AS-20240904133101

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a) · Plan of correction due date: Sep 11, 2024

Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on LPAs interview that staff was sleeping in the living room couch. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Staff should not be sleeping in the living room. Administrator will write LPA a letter and email to RO understanding this issue in order to be resolved.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 17, 2024

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPAs observation that the facility tap worker was not working. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Administrator needs to fix tap water faucet in the kitchen to have clean drinking water by 9.17.2024.

Type of visit: Case Management - Deficiencies

This case management visit is conducted by Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Gina Saucedo, in conjunction with a complaint investigation visit to this facility. On 9.10.2024, LPAs conducted an unannounced complaint visit to this facility in conjunction with complaint control #31-AS-202409041331017. LPAs met with the staff Isaiah Phiri, and the reason for the visit was disclosed. LPAs could not conduct a records review of residents and staff. Staff designee could not release records to LPAs for review. Therefore, interview with administrator over the phone, it was concluded that the facility did not provide records required for LPA. The designee MUST be able to act in administrator stead including but not limited to accessing files and records at any time. Under Title 22 Regulations, the following citation is issued and recorded on LIC809-D. No immediate health and safety hazard is noted at the time of this visit. Exit interview was conducted. Appeal rights discussed and a copy of report was issued.the state’s words, verbatim · CDSS document, Sep 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 874059(a) · Plan of correction due date: Sep 24, 2024

When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have the qualifications adequate to be responsible and accountable for management and administration of the facility. Based on LPA’s observations and interaction with the administrator, the administrator refused to respond to the facility to provide records to the LPA and had no Designee to act in his stead. This resulted in a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Administrator or designee should provide proper records for LPA to review when a visit is conducted. The designee MUST be able to act in administrator stead including but not limited to accessing files and records at any time.

Allegation investigated: Staff did not treat resident with dignity and respect

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a initial complaint visit to the facility to investigate the above allegations. LPA met with designee staff member Isiah Phiri and was advised about the visit. Administrator was not available; staff called administrator and advised the reason of the visit over the phone. An entrance interview was conducted. Today's investigation involved interviews with the administrator, staff, and residents. LPA also conducted a physical plant inspection of the facility at 8:40 AM to ensure the health and safety of the residents and a review of records. At 9:33 AM, LPA requested the resident and staff roster. During the investigation, interviews and record reviews were made. Continue to LIC 9099-C Unsubstantiated At 9:40 AM, LPA requested copies of pertinent information which include, but are not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan/Individual Program Plan (IPP), LIC 500, LIC 9020 and documents relevant to the investigation. Between 8:32 AM to 9:34 AM, LPA interviewed the Administrator over the phone, two (2) staff, and five (5) residents. Allegation: Staff did not treat resident with dignity and respect Regarding the allegation, it was alleged that on July 12, 2024 (Friday) at 11:30AM in the living room of the facility, the licensee was harassing and retaliating against Resident #1 (R1) regarding a rent increase beginning September 12, 2024. R1 advised LPA that they have been paying the same rate of $550 for a year and a half (1.5 years). LPA receive a copy of sixty (60 )-day notice regarding rate increase and not an eviction letter. There was one (1) staff and three (3) resident witnesses identified to confirm these allegations were not true. Furthermore, four (4) out of five (5) of the residents also deny the allegations, with several residents stating staff and administrator treats them cordially and speak to them respectfully. Based on the information, there was insufficient evidence to corroborate the allegations of the licensee not treating residents with respect, or the licensee harassing and retaliating at residents. Therefore, the allegation is deemed unsubstantiated at this time. The administrator advised and a copy of this report was issued.the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 31-AS-20240712144416

Allegation investigated: Staff handled resident roughly. Staff did not change resident timely. Staff did not shower resident timely Staff did not provide resident privacy Staff spoke to resident inappropriately Staff did not provide resident's food of nutritious quality to meet resident's needs.

This is an amended report due to clerical error. On 02.17.2023 LPA Angela Panushkina was the one who initiated the investigation for the complaint not Melissa Ruiz. On 03.20.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Isiah Phiri (S2) who granted access. S2 contacted the administrator Andranik Kapikyan (S1) to advise that LPA was at the facility. The administrator arrived at 2 PM, and LPA explained the purpose of the visit. At 12:25 PM LPA conducted a physical plant tour to ensure the health and safety of the residents in care. Allegation: Staff handled resident roughly Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit. Regarding the allegation above it is alleged that facility staff handled resident R1 roughly. On 02.17.2023 LPA Melissa Ruiz initiated this investigation for the complaint. Continue to LIC 9099-C Unsubstantiated Regarding the allegation “Staff handled residents in care in a rough manner” it was alleged staff have aggressively grabbed and pulled R1. According to R1, there was no bruising, staff grabbed R1's wrist roughly. LPA interviewed staff and residents on 03.20.2024 from 1:30 PM to 2:15 PM. Five (5) out of six (6) residents interviewed stated they had never experienced or witnessed staff handling residents roughly. Residents interviewed had no concerns about staff handling residents roughly or inappropriately. LPA interviewed the administrator and two (2) out of two (2) staff stated they do not handle residents roughly nor have they seen staff handling residents roughly. Staff interviewed stated they have not handled residents roughly nor heard of any other staff handling residents roughly. Based on interviews, residents were not handled rough manner by staff. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Allegation: Staff did not change resident timely It was alleged that R1's diaper would be soiled and soaked, and R1 needed to yell and wait for staff to change their diaper. Interviews with the administrator and two (2) staff revealed that all residents are checked or changed at least every three (3) hours or as needed. Moreover, LPA was informed that five (5) out of six (6) residents when they ask for help with toileting needs the staff immediately would assist. LPA was able to interview five (5) out of six (6) residents regarding this allegation. Residents interviewed confirmed that they are assisted to be taken to the restroom whenever they request which has not been a concern. Based on interviews, this allegation is deemed UNSUBSTANTIATED at this time. Allegation: Staff did not shower resident timely It was alleged that R1 would receive showers only once or twice a week and wanted more when needed. R1 stated that staff would ignore and refuse R1's requests for shower. To investigate the allegation LPA Leslie Ngo-Castaneda interviewed the administrator and two (2) staff out of two (2) staff and five (5) out of six (6) residents. Residents reveal that they are happy with staff help with shower care. Residents reveal that they never have any issues with showering. Hospice nurses help with R2 and R3 with showers. Staff interviews reveal that staff assist promptly and are fully staffed to assist residents with showers. Continue to LIC 9099-C Document review revealed that R2 and R3 do need assistance with the shower and received it as scheduled. Based on observation, interviews, and document review there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not provide resident privacy It was alleged staff did not respect the client's privacy. Staff would just barge into their room without knocking or leave their room ajar so that staff could eavesdrop on their conversation. During today's visit, from 11:30 AM to 2:15 PM. LPA conducted a physical plant inspection and interviewed the administrator, (2) staff, and five (5) out of (6) clients. Based on interviews, clients reported to LPA that staff knock on the door before they enter, and their privacy is respected. Although it was reported that some of the clients do not answer their door when staff call them or leave their bedroom door open, staff still knock on their door before they enter, based on interviews, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff spoke to resident inappropriately In regards to the allegation, it was alleged that while R1 is wheelchair bound, staff would approach R1 and aggressively yell or curse out R1. There were no witnesses or suspects identified to the allegation. Nor was there a date and time given. Interviews with the administrator and two (2) staff deny such allegations had occurred since their employment. LPA interviewed five (5) out of (6) residents that they were happy and satisfied with the facility and care from staff. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff speaking inappropriately to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Allegation: Staff did not provide resident's food of nutritious quality to meet resident's needs Regarding the allegation that the food is not nutritious enough to meet the needs of residents, it was alleged that the facility is only serving "junk food". LPA observation today revealed that the facility's lunch today consists of salad and hamburger. For breakfast, residents and staff advised LPA that hot cereal was served. LPA observation also revealed that today, they have an alternate menu in case a resident does not like what they are serving for lunch today. Continue to LIC 9099-C LPA interview with five (5) out of six (6) residents today between 11:30 AM to 2:15 PM revealed that five (5) out of six (6) residents like the food served today and likes the food at the facility in general. All five (5) residents also stated that the food served was nutritious enough for them. Based on the information gathered during this visit, the above allegations are deemed UNSUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 31-AS-20230213141642

Allegation investigated: Staff would not allow resident to come back to the facility. Staff would not give resident their personal property. Staff did not give resident medication

Licensing Program Analysts (LPA) Leslie Ngo-Castaneda conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Andranik Kapikyan and advised administrator of the allegations. During the course of the investigation, LPA conducted interviews clients in the facility at 1:010 PM. With the assistance of the staff at 1:05 PM LPA took a facility tour. Allegation #1: Staff would not allow resident to come back to the facility In regards to the allegation, it was reported that the resident did not allow resident to come back to the facility due to their monthly dues. Interviews with residents in the facility revealed that no incident occurred during their stay in the facility. They are all content with the facility and have no issues with coming and going out of the facility. Staff interviews reveal that they always try to meet the client’s needs. Review of facility records also confirms that staff training and facility program was reviewed by all the staff. Cotinue to LIC 9099-C Unsubstantiated Based on the information obtained, there was insufficient evidence to corroborate the allegation. Therefore, the allegation of staff not properly trained is unsubstantiated at this time. Allegation #2: Staff would not give resident their personal property Regarding the allegation, it was reported that staff would withhold resident belongings for dues not being paid. Interviews with residents do not corroborate with the allegation. Interviews with staff do not coincide with the allegation since the facility does not want any of the resident belongings. Therefore, based on the information obtained, the allegation of staff would not give residents their personal property is deemed unsubstantiated at this time. Allegation #3: Staff did not give resident medication In regards to the allegation, it was reported that the resident medication was withheld in the facility for not paying monthly dues. During the course of the visit, LPA did review of records of resident medication records and medication was given to the resident and signed-off by the staff on the Centrally Stored Medication and Destruction Records (CSMDR). Based on the information obtained, there was insufficient evidence to corroborate the allegation of resident medication being withheld. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued to the administrator.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 31-AS-20230131130307

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. At 9:22 am Andarik Kapikyan who is the administrator met with LPA, explained the reason for the visit. At 9:45 am, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 7/13/2023. During the visit the facility is at 65 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents. Hospice waiver for six (6). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen below the sink. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1 and bedroom #2 is private, but bedroom #3 and bedroom #4 are shared and is used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bathrooms: There are two (2) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 108 degrees Fahrenheit for bathroom #1 located in the hallway beside bedroom #2. Bathroom #2 is inside bedroom #3. There was enough clean linen available in the cabinets in the laundry room. Continue to LIC 809-C Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool it is fence up and lock. The garage is detached and is converted into an office. Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located outside the patio. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Continue to LIC 809-C Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisal. Planned activities are offered. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, Jan 25, 2024

Allegation investigated: Facility staff is retaliating against resident for filing a complaint Staff threatened resident with eviction

There are two allegations: On 1.10.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced visit to address this complaint. LPA met initially met with staff Isiah Phiri who contacted the administrator. Administrator Andranik Kapikyan arrived at 10:20AM. LPA explained the reason for the visit. Entrance interview conducted. LPA conducted physical plant tour at 9:35am. At 9:40am LPA interviewed six (6) residents and reviewed resident records for any possible eviction notices. Continue to LIC 9099-C Unsubstantiated Allegation: Facility staff is retaliating against resident for filing a complaint. Interviews indicated that four (4) out of six(6) residents did not witness any retaliatory behavior from the Administrator towards resident #1 (R1). No residents witnessed the Administrator approach or hear any conversations that may be taken as retaliatory. In interviewing the Administrator, he stated he did not approach the resident or saying anything regarding this allegation. Therefore, after review of the information and due to a lack of witnesses the allegation cannot be corroborated and is unsubstantiated at this time. Allegation: Staff threatened resident with eviction. Regarding the allegation of eviction, LPA conducted a file review during the investigation and did not observe any eviction notice in the file. LPA interviewed R1 and no eviction notice was received. LPA interviewed the Administrator and the administrator indicated that no eviction notice was issued nor was there any threat to R1 to leave. Interview with the other (number ) resident were conducted and not one witnessed any threats made by the Administrator to R1. Therefore, after review of the information and due to a lack of witnesses the allegation cannot be corroborated and is unsubstantiated at this time. Exit interview conducted.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 31-AS-20240104081845

Allegation investigated: Staff do not ensure a safe and healthful environment is provided for resident. Staff do not safeguard resident's personal belongings.

This an AMNDED report as further rewview of defciencies and fine that was issued incorrectly. This is to state that NO FINE has been cited and issued to facility. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent complaint visit to deliver the finding for the above stated allegation. LPA met with the administrator and explained the reason for the visit. Entrance interview. Allegation: Staff do not ensure a safe and healthful environment is provided for resident. On 01-03-2024 LPM Gillyard and LPA Ngo-Castaneda initiated the visit. On this day, the home was observed to have a malodorous scent of urine. A black moldy patch was observed in room (3) on the base of the wall in size of 2x2. The wall paint was puckers due to water damage. The Administrator made observations and acknowledged indicating that there needs to be plumbing work done in the hallway bathroom. Continue to LIC 9099-C Substantiated Today LPA conducted a tour of the home (time). LPA observed malodorous urine odor upon entering the home. During the facility tour LPA observed mold which was seen in resident bedroom #3 on the left side bottom corner wall by the entrance as seen on 01-03-2023. At 9:35am LPA interview with R1 revealed and confirmed that there is mold in the facility of bedroom #3. In addition, interviews indicate that R2 would throw soiled diaper across bedroom #2 wall. Upon further inspection of the facility LPA observed that bedroom #4 has an odor. Interview with all staff members, confirmed that the facility has did not provide a clean and safe environment for the residents in care. The facility tried to paint over the mold, repair and clean the rooms but was unsuccessful. Allegation: Staff do not safeguard resident's personal belongings. Upon further investigation it was also alleged that facility did not safeguard resident # 1 personal belongings. Upon resident interview and review of pictures and videos it was discovered that R2 would wear roommates clothing without permission. R1 did not give permission to roommate for them to go through their belongings. Staff did not redirect roommate. Therefore, based on interviews, observation, and document review, there is a sufficient information to support the allegation. Therefore, this allegation is deemed Substantiated. Deficiencies were issued and recorded on LIC9099D. Exit interview conducted. Report signed and delivered. Appeal rights delivered.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 31-AS-20231227160159

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 10, 2024

The facility shall be clean, safe, sanitary at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by: Based on inspection, and observation. The licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others.LPA observed mold and odor in residents’ bedrooms and facility entrance. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: The administrator will take all measures to maintain the facility free from odor and mold. Administrator will submit updated documentation of repair to LPA via email 1.22.2024. This is an AMEND that no civil penalty is issued in the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Jan 10, 2024

Personal Accommodations and Services (d) The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by: This was observed with LPM and LPA R1 used a white shoelace like rope to tie the handles of the cabinet to safeguard belongings. The allegation is substantiated and is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: The administrator will need to provied a lock to keep the belongings safe for the residents by 1.20.2024

Allegation investigated: Facility has mold.

This is an amendment of the original report issued 01-10-2024 to clarify the complaint findings. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent complaint visit to deliver the finding for the above stated allegation. LPA met with the administrator and explained the reason for the visit. Today 1.10.2024 LPA conducted a tour of the home at 9:35AM. A black moldy patch was observed in bedroom three (3) on the base of the wall 2x2 inches in size. The Administrator (S1) was aware and acknowledged the presence of mold on the base of the wall in bedroom #3 and stated that there was a plumbing issue in bedroom #3 bathroom which caused the mold. The Administrator advice LPA that this is scheduled to be fixed and removed on 1.15.2024. An interview with staff member (S2) also confirmed and acknowledged mold formation in bedroom #3. Therefore, based on interviews, observation, and document review, there is sufficient information to support the allegation. Therefore, this allegation is deemed Substantiated. Deficiencies were issued and recorded on LIC 9099-D. Exit interview conducted. Report signed and delivered. Appeal rights delivered. Substantiatedthe state’s words, verbatim · CDSS document, Jan 10, 2024 · control 31-AS-20240104131120

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jan 10, 2024

The facility shall be clean, safe, sanitary at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by: Based on inspection, and observation the licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed mold in residents’ bedroom # 3. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: The administrator will take all measures to maintain the facility free from mold. Administrator will submit updated documentation of repair to LPA via email for the invoice and picture of mold was removed on 1.21.2024.

Type of visit: Case Management - Deficiencies

This is a AMENDED report as after further review of the substantiated and deficiency findings on 1/10/24 of the above-mentioned allegation. Civil penalty has been removed and corrected. NO FINE on facility. On 1.10.2024, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility. LPA was greeted by staff Isiah Phiri (S1) and later met with Administrator Aranik Kapikyan. The purpose of this Case Management – Deficiencies report is to address deficiencies found during the complaint investigation, control number 31-AS-20231227160159. LPA conducted a physical plant tour and at 9:2 AM, LPA observed that three (3) out of six (6) clients needed assistance for changing, food preparation, and cleaning. LPA Ngo-Castaneda observed a resident was left alone on 1.10.2024 without staff present to meet R2, R4 and R5's needs. A copy of the LIC 500 was provided to LPA Ngo-Castaneda. Administrator did not provide incontinent management program for R2, this was already address during the initial visit. According to R1, R2’s soiled diaper is expose in the hallway for staff to clean-up. R2 used to throw soiled diaper across the bedroom with R1. LPA also observed during the visit that a urine odor is present in the residents bedroom hallway. Based on observation, deficiencies issued per CA Code of Regulation, Title 22. See 809-D. Exit interviewed discussed, appeal rights were given to the caregiver and a copy of the signed report was given to administrator.the state’s words, verbatim · CDSS document, Jan 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411 · Plan of correction due date: Jan 10, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Administrator needs to have another hire and have at least two (2) staff in the facility during the visit. A new LIC 500 is needed, this would be sent via email from administrator. NO civil penalty has been issued.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87625(b)(3) · Plan of correction due date: Jan 10, 2024

Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Administator needs to updated on bowel and bladder plan for R2. An update on resident appraisal as well. Administrator will email to LPA. NO civil penalty has been issued.