Palace of Joy

Type of visit: Case Management - Other

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted a case management visit to verify proper medication administration and management for residents in care. LPA met with the staff and the Administrator was contacted via telephone. LPA explained the reason for the visit. The Administrator left the facility and assigned the Licensee to sign and receive today's report. During the visit, LPA reviewed R1’s Centrally Stored Medication Record (CSMR), medication packaging, and medication counts. On 09/02/2026, LPA identified the following discrepancies: Amlodipine: One tablet discrepancy; 45 tablets were present instead of the expected 46. Divalproex Sodium: One day’s dose remained in the bubble pack, indicating one missed dose. Escitalopram: Two tablets were missing from the new bubble pack. Vitamin B1: New bubble pack was started on 08/31/2026 instead of 08/30/2026, indicating a missed/delayed dose. Celecoxib: Medication supply was exhausted on 08/28/2026. R1 had not received the medication since the evening of 08/28/2026, and no refill was available from the pharmacy. Trazodone: One extra tablet remained in the bottle, and the new bubble pack had not been started as scheduled. No discrepancies were identified for Tamsulosin, Docusate Sodium, or Atorvastatin. LPA determined that the facility failed to timely notify R1’s physician and Community Care Licensing Division (CCLD) regarding the medication discrepancies and Celecoxib interruption. LPA discussed the findings with the Administrator and advised that medications must be administered as prescribed, discrepancies and medication interruptions must be immediately addressed and documented, and required notifications must be made timely.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 3, 2026

87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above by failing to ensure that R1’s prescribed medications were administered as ordered, medication discrepancies were timely addressed, and R1’s physician and CCLD were timely notified of medication errors and the interruption of prescribed medication. This poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: The Licensee agreed to schedule vendorized training for all staff by 9/3/26 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)A,B&D · Plan of correction due date: Sep 9, 2026

(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD and R1's Physician regarding R1's medication discrepancies, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: The Licensee agreed to notify R1’s physician and submit an incident report to CCLD regarding R1’s medication discrepancies identified during LPA’s review on 09/02/2026. The discrepancies involved medications prescribed from 06/01/2026 through 08/29/2026, during which period the medications were expected to be administered as prescribed.

Allegation investigated: Staff scream at residents.

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced initial complaint visit to investigate the above stated allegations. LPA met with the Staff #1 (S1) who granted access to the facility. S1 contacted the Administrator and LPA explained the reason for the visit. The Administrator arrived shortly after. During the course of the investigation, LPA conducted interviews, reviewed pertinent records, and conducted a physical plant tour. At 9:35 AM, LPA requested the resident and staff rosters. At 9:40 AM, LPA requested pertinent records relevant to the investigation, including, but not limited to, Physician's Reports, Appraisal Needs and Services Plans, staff training records, sample menus, and other applicable documentation. At approximately 9:45 AM, LPA conducted a physical plant tour of the facility. Between 9:50 AM and 12:30 PM, LPA conducted interviews with the Administrator, Staff #1 (S1), and four (4) of five (5) residents who were available. Continue on LIC 9099C Substantiated Allegation: Staff scream at residents. It was alleged that facility staff screamed at residents. To investigate this allegation, LPA conducted interviews with the Administrator, Staff #1 (S1), and four (4) out of five (5) residents who were available. The Administrator and S1 denied ever screaming or yelling at residents in care. The Administrator stated that staff are expected to remain professional and respectful when interacting with residents. Three (3) of the four (4) residents interviewed denied hearing staff scream or yell at residents and denied being screamed or yelled at by staff. One (1) resident reported witnessing a staff member yell at Resident #2 (R2). During the investigation, LPA directly observed the licensee interacting with Resident #1 (R1). LPA observed the licensee raise their voice and scream at R1. LPA further observed the licensee become visibly agitated and act aggressively toward R1 during the interaction. Although the Administrator, S1, and three (3) residents denied witnessing or experiencing staff yelling or screaming at residents, one (1) resident provided information consistent with the allegation, and LPA directly observed the licensee scream at R1 during the investigation. Based on LPA's direct observation and the information obtained through interviews, there is sufficient evidence to establish that the alleged conduct occurred. Therefore, the allegation that staff scream at residents is deemed Substantiated. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered. Allegation: Staff are not meeting resident’s showering needs. It was alleged that facility staff are not meeting residents' showering needs. To investigate this allegation, LPA conducted interviews with the Administrator, Staff #1 (S1), and four (4) out of five (5) residents who were available. The Administrator and S1 stated that residents receive showers at least twice a week or as needed and may request additional showers. Both denied refusing or delaying residents' showers. One (1) resident requires assistance with showering and reported receiving regular showers. The resident denied being denied or delayed a shower or witnessing another resident being denied a shower. During the visit, LPA observed the residents to be clean and well-groomed and did not observe any concerns related to residents' showering needs. Based on interviews and LPA's observations, there was insufficient evidence to establish that staff failed to meet residents' showering needs. Therefore, this allegation is deemed Unsubstantiated at this time. Allegation: Staff do not provide adequate food service to residents. It was alleged that facility staff do not provide adequate food service to residents. To investigate this allegation, LPA conducted interviews with the Administrator, Staff #1 (S1), and four (4) out of five (5) residents who were available. LPA also conducted a physical observation of the facility's food supplies. The Administrator and S1 stated that residents are provided meals according to their preferences and dietary needs and that groceries are purchased regularly and as needed. Three (3) out of four (4) residents interviewed reported receiving meals regularly and denied concerns regarding the food service. During LPA's observation, the facility had approximately two (2) days of perishable food and one (1) week of non-perishable food available. Based on interviews and LPA's observation, there was insufficient evidence to establish that staff failed to provide adequate food service to residents. Therefore, this allegation is deemed Unsubstantiated at this time. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 31-AS-20260819115023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 1, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships....This requirement is not met as evidenced by: Based on interviews and LPA’s direct observation, the licensee did not comply with the section cited above by screaming at and acting aggressively toward Resident #1 (R1), which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: The licensee agreed to review residents’ personal rights and the staff and licensee will receive training on the section cited. Proof of staff/licensee training will be e-mailed to LPA by the POC POC due date.

Allegation investigated: Staff did not prevent a resident from smoking drugs inside the facility. Staff did not ensure that complete resident records were maintained at the facility.

At 9:45 a.m., Licensing Program Analyst (LPA) Huma Rahimi conducted a subsequent complaint visit to investigate the above-stated allegations. LPA met with Staff #1 (S1), Lourdes Zapata, and the staff contacted the Administrator by telephone. LPA explained the reason for the visit, and the Administrator arrived shortly thereafter. An initial complaint visit was conducted on 12/10/2025. During that visit, LPA obtained copies of the client and staff rosters. LPA interviewed the Administrator. At 9:40 AM, LPA requested copies of resident documentation. The Administrator informed LPA that, in accordance with the three (3) years retention practice, all resident records older than three (3) years had been purged and were no longer available for audit or review During today's visit, between 10:00 am to 12:00 pm, LPA conducted interview with the Administrator, two (2) staff, and two (2) out of four (4) residents who were avaliable. At 12:10 PM, LPA conducted file review of four (4) out of four (4) residents. Continue on LIC 9099C Unsubstantiated Staff did not prevent a resident from smoking drugs inside the facility. It was alleged that staff did not prevent a resident from smoking drugs inside the facility. To investigate, LPA conducted interviews with the Administrator, two current staff, and two (2) out of four (4) residents who were available. The Administrator denied the allegation and stated the facility maintains a strict no-drug policy and that staff supervision is provided at all times. The Administrator confirmed one resident death occurred in September 2022 while receiving hospice services for end-stage heart failure but denied any knowledge of drug use. Staff reported they were not employed at the facility in September 2022 and have never observed drug or alcohol use. Staff also confirmed that all resident rooms are monitored and that no residents currently require oxygen. Interview with two (2) out of four (4) residents stated that drugs are not used at the facility, substance use is prohibited, and staff maintain resident safety. Based on interviews and observations, there is insufficient evidence to support the allegation. This allegation is Unsubstantiated at this time. Staff did not ensure that complete resident records were maintained at the facility. It was alleged that staff did not maintain complete resident records. To investigate, LPA conducted interviews with the Administrator, two current staff, and two (2) out of four (4) residents who were available, and reviewed current resident files. The Administrator stated that all required documentation, including Admission Agreements, Physician’s Reports, and Appraisal/Needs and Services Plans, are maintained at the facility. The Administrator further stated that records older than three years are purged in accordance with Title 22 CCR. Staff confirmed that records are securely stored, accessible during emergencies, and complete. Interview with two (2) out of four (4) residents confirmed that their medical and non-medical records are complete and accessible, and emergency personnel have never been unable to access records. During today's visit, LPA reviewed four (4) out of four (4) resident files and observed documentation was complete, organized, and maintained in compliance with regulatory requirements. Based on interviews and record review, there is insufficient evidence to support the allegation. This allegation is Unsubstantiated at this time. Appeal rights explained and exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 31-AS-20251208091849

Allegation investigated: Staff untrained providing care and supervision to residents. Staff unable to communicate residents needs due to language barrier. Staff does not follow food menu.

At 9:10 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced subsequent complaint visit to investigate the above stated allegations. LPA met with the Administrator and explained the reason for the visit. On 12/10/2025, the LPA conducted the initial visit. At approximately 9:35 AM, the LPA requested the resident and staff rosters. At approximately 9:40 AM, the LPA requested copies of pertinent records relevant to the investigation, including staff training records, facility policies, and the facility’s food menu. At approximately 9:45 AM, the LPA conducted a physical plant tour. Between approximately 9:55 AM and 10:00 AM, the LPA conducted an interview with the Administrator. On 02/10/2026, during the subsequent visit, between approximately 9:30 AM and 1:20 PM, the LPA conducted interviews with two (2) staff and four (4) out of four (4) residents. At approximately 1:25 PM, the LPA reviewed resident records and staff training records relevant to the investigation. Continue on LIC 9099C Unsubstantiated Allegation: Staff untrained providing care and supervision to residents. It was alleged that staff were untrained and providing care and supervision to residents. To investigate, LPA interviewed the Administrator, Staff #1 (S1), Staff #2 (S2), and four (4) out of four (4) residents, and reviewed staff training records. The Administrator stated that all direct-care staff receive initial training upon hire, including dementia care, medication administration, residents’ rights, facility policies, and reporting requirements, and competency is verified through daily observation by the Administrator. S1 and S2 stated they received initial and ongoing training and are able to perform assigned duties. During the facility tour and observations, LPA noted staff providing care and supervision to residents. Four (4) out of four (4) residents interviewed stated their care needs are being met and expressed no concerns. Based on interviews, record review, and observations, this allegation is Unsubstantiated. Allegation: Staff unable to communicate residents’ needs due to language barrier. It was alleged that staff were unable to communicate residents’ needs due to a language barrier. To investigate, LPA interviewed the Administrator, S1, S2, and four (4) out of four (4) residents. The Administrator stated that at least one English-speaking staff member is present on each shift. S1 and S2 stated they communicate effectively with residents. During the facility tour and observations, LPA noted staff effectively communicating with residents, and residents responding appropriately. Four (4) out of four (4) residents interviewed stated they are able to communicate their basic needs and had no concerns. Based on interviews and observations, this allegation is Unsubstantiated. Allegation: Staff does not follow the posted food menu It was alleged that staff failed to follow the posted food menu and provided a poor diet to residents in care. To investigate, LPA interviewed the Administrator, Staff #1 (S1), Staff #2 (S2), and four (4) out of four (4) residents. LPA reviewed the facility’s sample menu and observed food items in the refrigerator and throughout the facility that matched the sample menu. During the initial and subsequent complaint visits, LPA conducted a physical plant tour and observed nutritious food available to residents. All four (4) residents interviewed stated that meals are adequate and not poor in quality. Based on interviews, record review, and observations, this allegation is Unsubstantiated. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 31-AS-20251209103650

Allegation investigated: Staff unable to meet residents needs due to language barrier.

At 9:45 a.m., Licensing Program Analyst (LPA) Huma Rahimi conducted a subsequent complaint visit to investigate the above-stated allegation. LPA met with Staff #1 (S1), Lourdes Zapata, and the staff contacted the Administrator by telephone. LPA explained the reason for the visit, and the Administrator arrived shortly thereafter. An initial complaint visit was conducted on 06/23/2025 by LPA Leslie Ngo-Castaneda. During that visit, LPA obtained copies of the client and staff rosters, residents’ physician reports, admission agreements, appraisals, and other relevant documents. LPA also conducted a physical plant tour of the facility. Interviews were conducted with the Administrator, three (3) staff members, and six (6) out of six (6) residents. During today's visit LPA Rahimi, conducted a physical plant tour of the facility. Continue on LIC 9099C Substantiated Allegation: Staff unable to meet residents needs due to language barrier. It is alleged that facility staff are unable to meet resident needs due to a language barrier. To investigate this allegation, on 06/23/2025, LPA Ngo-Castaneda conducted interviews with the Administrator, residents, and staff, and observed staff-resident interactions. During the inspection, LPA experienced difficulty communicating with staff and observed staff relying on cellular telephone translation applications to communicate with residents. LPA Ngo-Castaneda noted inaccuracies in the translations. One resident reported feelings of fear and frustration when attempting to communicate their needs due to unreliable translation. For the first two (2) hours of the initial inspection conducted on 06/23/2025, the only staff present at the facility were non-English-speaking staff. After approximately two (2) hours, an additional staff member arrived who was able to communicate in English. Interviews with five (5) out of six (6) residents confirmed that staff frequently use cellular telephones to communicate. The Administrator acknowledged that some staff have a language barrier and rely on translation tools. Based on interviews and direct observation, LPA determined that language barriers impacted effective communication with residents, the majority of whom speak English, regarding their basic needs and services. Therefore, this allegation is deemed Substantiated. A deficiency was issued, and appeal rights were explained. An exit interview was conducted, and a copy of this report was signed and delivered. Allegation: Staff did not administer resident’s medication as prescribed. It is alleged that facility staff did not administer Resident #1’s (R1) medication as prescribed. To investigate this allegation, on 06/23/2025, LPA Ngo-Castaneda conducted interviews with the Administrator, facility staff, residents, a hospice nurse, and a witness. The Administrator and staff stated that all medications are administered according to physician’s orders and stored in a locked medication cabinet in compliance with Title 22 regulations. Staff reported that R1 requested to keep prescribed eye drops in their room; however, medications are not permitted to be kept in resident rooms. Interview with a witness confirmed that R1 receives medications as prescribed. Interview with the hospice nurse assigned to another resident confirmed medications observed at the facility were in order. Interviews with five (5) out of six (6) residents stated they receive medications as prescribed and did not express concerns regarding medication administration. Based on interviews and observations, there was insufficient evidence to support the allegation; therefore, this allegation is deemed Unsubstantiated at this time. Allegation: Staff discarded resident’s personal belongings. It is alleged that facility staff discarded Resident #1’s personal belongings without consent. To investigate this allegation, on 06/23/2025, LPA Ngo-Castaneda conducted interviews with the Administrator, staff, and residents. The Administrator and staff informed LPA that the facility only removed hazardous items such as razors, scissors, bodily waste, and spoiled food during cleaning for health and safety reasons only. Staff denied discarding non-hazardous personal belongings. Interviews with five (5) out of six (6) residents stated they have not had personal belongings thrown away without their permission. Interview with the witness confirmed that R1 tends to hoard and bring dangerous items to the facility. Therefore, based on interviews this allegation is deemed Unsubstantiated at this time. Allegation: Staff not providing adequate food service to resident. It is alleged that facility staff do not provide adequate food service to residents. To investigate this allegation, on 06/23/2025, LPA Ngo-Castaneda conducted interviews with the Administrator, staff, and six (6) out of six (6) residents. Continue on LIC 9099C The Administrator and staff stated that meals provided include protein such as chicken, beef, eggs, and sausage. Staff further reported that some residents maintain personal refrigerators for preferred food items. Interviews with five (5) out of six (6) residents did not express any concerns regarding food quality and reported that food portions were adequate and acceptable. The hospice nurse stated that nutritious food was observed during lunch/mealtime. During today’s visit, LPA Rahimi conducted a physical plant tour of the facility and observed that the facility’s food supply included milk products, meat, vegetables, fruits, bread, cereals, juices, and desserts. Based on interviews and observations, there was insufficient evidence to support a violation related to food service. Therefore, this allegation is deemed Unsubstantiated at this time. Allegation: Staff restricting resident from leaving the facility. It is alleged that facility staff restrict R1 from leaving the facility. To investigate this allegation, on 06/23/2025, LPA Ngo-Castaneda interviewed the Administrator, staff, and five (5) out of six (6) residents. The Administrator and staff stated residents are not restricted from leaving; however, supervision is required for certain residents per Physician report/order. Additionally, staff reported accompanying residents when necessary for safety reasons. Interviews with five (5) out of six (6) residents stated they are not restricted from leaving the facility and may access outdoor areas freely. Based on interviews and evidence, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 31-AS-20250618111717

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Dec 30, 2025

87411-Personnel Requirements General-(d)(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.,.This requirement is not met as evidenced by: Based on LPA Ngo-Castaneda’s interviews and observation, the administrator does not have staff available to communicate with residents to provide care which poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The Administrator agreed to have at least one English-speaking staff on each shift. The administrator will monitor staff schedules and resident interactions weekly to ensure compliance. Currently the Administrator has one staff on each shift who speaks English. POC cleared during today's visit.

Type of visit: Required - 1 Year

At 10:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with Lourdes Zapata, Caregiver, who granted access to the facility. The Administrator Marine Grigoryan was contacted via a telephone and LPA explained the reason for the visit. The Administrator arrived at the facility at 11:00 AM. LPA was informed that the facility currently has six (6) residents, of which two (2) residents are non-ambulatory. Three (3) residents are currently on hospice. Facility has waiver for 4 hospice residents. KITCHEN: LPA observed the kitchen area equipped with a refrigerator, microwave oven, and a sink. Stove was observed in a good working condition. At 11:10 AM, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents in care. LPA observed a Fire Extinguisher and was purchased on 11/17/2025. It was observed hanging on the wall by the bathroom in the main hall. MEDICATION ROOM: The centrally stored medication are kept in the in a locked cabinet in the main hall by the kitchen. Residents and staff files are also kept in a cabinet locked and inaccessible in the main hall by the kitchen. During review of 23's random medication revealed that the facility was supposed to start Carvedilol 12.5MG (Hypertension Medication) a new bottle on 10/16/2025. During today's visit LPA counted R2's medication and it was discovered that there was a discrepancy and twenty two (22) extra pills were in the bottle. LPA asked the Administrator and the staff for explaining and both staff and the Administrator could not provide any answers. Continue on LIC 809C BEDROOMS: There are four (4) bedrooms designated for resident’s use. Two (2) bedrooms are shared and two (2) are private. Bedroom #4 is for bedridden resident. LPA observed that the bedridden bedroom exit was being blocked by a wheelchair. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. LPA observed Tylenol tablets, and Mylanta liquid in Bedroom #4 accessible and unlocked to residents in care. Auditory alarms were tested and observed to be non-operational. BATHROOMS: There are three (3) bathrooms at the facility. Two (2) out of three (3) bathrooms are designated for resident's use. One of the bathrooms is located at the end of the kitchen is only being used by the staff and visitors. Bathroom #1 is located in the hallway and bathroom # 2 is connected with bedroom #4. LPA observed all residents' bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat The water temperature was noted at 131.1°. LAUNDRY ROOM: The laundry room is located by the kitchen. All the cleaning supplies and laundry detergents were observed locked in a locked box in the backyard of the facility. The washer/dryer appear to be in good working condition. COMMON AREAS: The facility maintains a comfortable temperature at 77°F. The living room and dining area appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPA observed a working telephone for the facility. SURROUNDING GROUNDS: The facility has sufficient backyard space. LPA did not observe any shaded area. LPA observed the furniture; however, they were not properly placed for residents to sit. The furniture were scattered around in the backyard. LPA observed a swimming pool which was locked and properly fenced. Garage/Storage: The facility does not have any extra garage/storage space. Continue on LIC 809C SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:30 AM, they were tested and observed to be operational. Between 12:00 PM to 2:00 PM, LPA reviewed records of six (6) residents and two (2) staff records. All residents and staff records were updated and completed. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. Deficiencies issued and appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 17, 2025

Allegation investigated: MStaff are not meeting resident's toileting needs. Staff are not meeting resident's hygiene needs. Staff are not adhering to sanitation protocols.

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with staff Keneshbek Minzhasharov and the staff contacted the Administrator via phone. LPA explained the reason for the visit. During course of the investigation, interviews and record review were made. At 9:35 AM, LPA requested resident and staff roster. At 9:40 AM, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician Report, Appraisal Needs and Services Plan, Centrally Stored Medication Destruction (CSMD) and etc., relevant to the investigation. At approximately 9:45 AM, LPA conducted a physical plant tour. Between 9:55 AM – 12:45 PM, LPA conducted an interview with the Administrator, a staff, and five (5) out of sxi (6) residents who were able to communicate. Continue on LIC 9099C Unsubstantiated Staff are not meeting resident's toileting needs. It is alleged that the facility staff is not able to change Resident #1 (R1) due to the religion restriction of the staff and R1 was covered with feces. To investigate this allegation LPA conducted an interview with the Administrator and it was revealed that on 05/02/2025, R1 was taken care of for the toileting needs accordingly; however, due to the constipation issue R1 was unable to have a normal bowel movement. Additionally, staff place R1 on a bed side commode and again R1 was unable to have any bowel movement. Due to R1 becoming weak R1 asked the staff to place him/her in bed. Later, after R1 made his/here business (bowel movement) in bed and touched his/her own feces. R1 called the staff and asked to be cleaned. Furthermore, interview with two staff confirmed the information provided by the Administrator and informed LPA that the staff are always available to provide all required care including toileting needs. Interview with five (5) out of six (6) residents including R1 stated that the facility staff do meet toileting needs of all the residents in a timely manner and did not express any concerns regarding the above allegation. Therefore, based on the information provided through interviews this allegation is deemed Unsubstantiated at this time. Staff are not meeting resident's hygiene needs. It is alleged that R1's phone was filled with feces, and R1 was unable to receive phone calls. Moreover, it is alleged that R1's environment is not clean and sanitary in the facility. To investigate this allegation LPA conducted an interview with the Administrator and it was revealed that on 05/02/2025, R1 had constipation issue. The staff provided bed side commode and R1 was unable to have a bowel movement. Eventually, R1 had a bowel movement in his/her bed. As a result, , R1's phone that was placed in bed got covered with R1's feces. Interview with two staff revealed that after the incident R1, the bed, and the phone were cleaned immediately. Furthermore, LPA conducted an interview with R1 who confirmed that the information provided by both staff and the Administrator. Moreover, R1 informed LPA that due to non-payment of the phone bill R1 was unable to receive any phone calls. Interview with residents stated that all of their hygiene needs are being met and expressed no concerns. Lastly, during today's visit, LPA observed that the facility is following all the hygiene needs of the residents including R1's. LPA observed that the facility is sanitary and clean including R1's room. Based on the interviews and LPA's observation during today's visit this allegation is deemed Unsubstantiated at this time. Continue on LIC 9099C Staff are not adhering to sanitation protocols. It is alleged that the facility staff used same gloves that they used to change one resident and changed another resident. To investigate this allegation LPA conducted an interview with the Administrator and two staff. All parties interviewed denied the above allegation and informed LPA that gloves are being changed after providing care and supervision to each resident. LPA was also informed that the same gloves cannot be used for several tasks. Furthermore, during today's visit LPA observed that both staff are wearing new gloves before serving a resident. Lastly LPA observed several boxes full of gloves being stacked in the kitchen closet. Therefore, based on interviews and observation this allegation is deemed Unsubstantiated. Exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 20, 2025 · control 31-AS-20250516105015

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi, met with the staff Keneshbek Minzhasharov, and the Administrator Marine Grigoryan was contacted via phone and LPA explained the reason for the case management visit. The purpose of the case management visit is to address deficiencies observed during the course of complaint # 31-AS-20250516105015, The deficiencies were not alleged but observed by LPA. During the visit, LPA was informed that R1 is having behavior issues/incidents on daily basis. Furthermore, on 05/02/2025, R1 had a bowel movement incident. On 03/27/25, R2 was taken to the hospital by calling 9-1-1 for shortness of breath. However, no incident reports were submitted to the Community Care Licensing Department (CCLD) in a timely manner for R1 and R2. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident/Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA informed the Administrator to submit an incident report that occurred on: 05/02/25 for R1 All other incidents (related to R1) 03/27/25 (R2) hospitalization Moreover, upon arrival to the facility LPA conducted interviews and concluded that two (2) out of two (2) staff were not able to communicate in English with the residents of which the majority speak English. Furthermore, interviews with five (5) out of six (6) residents who were able to communicate confirmed that Continue on LIC 809C they have trouble communicating with staff for their basic needs. Lastly, during today's visit both staff used translator application on their phone to communicate/interview with LPA. Therefore, a deficiency will be issued. Lastly, during the course of investigation LPA observed a small scratch on R2's nose. During the interview LPA was informed that R2 was physically abused by Staff #1 (S1). LPA observed that R2 was not consistent with the information provided to LPA. LPA conducted a file review of R2 and observed that R2 is diagnosed with dementia, schizophrenia, and bipolar disorder. Additionally, LPA conducted interviews with the Administrator, and two staff. All parties interviewed denied ever witnessing or physically abusing anyone in the facility. Therefore, due to the lack of evidence LPA was unable to conclude that R2 was ever physical abused by facility staff. Deficiencies cited during today's visit and appeal rights explained and given. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: May 27, 2025

87411-Personnel Requirements General-(d)(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.,.This requirement is not met as evidenced by: Based on LPA’s interview and observation, the administrator does not have staff available to communicate with residents to provide care which poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)A,B&D · Plan of correction due date: May 27, 2025

87211(a)(1)A,B&D-Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the section cited above by not notifying CCLD regarding R1's and R2's incident reports which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's and R2's incident reports shall be submitted to LPA by POC date.

Allegation investigated: Staff does not ensure medications are properly stored. Staff does not ensure food is properly stored. Staff does not ensure expired/ or rotten food are disposed. Staff does not ensure hazardous chemicals are properly stored Staff does not ensure dangerous items are properly stored.

At 9:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with staff Tynaibek Usupbaev and the staff contacted the Administrator via phone. LPA explained the reason for the visit. During course of the investigation, interviews and record review were made. At 9:10 AM, LPA requested client and staff roster. At 9:15 AM, LPA requested copies of pertinent information which include, but not limited to Staff Training, Dementia Program, Medication Policy and etc., relevant to the investigation. At approximately 9:25 AM, LPA conducted a physical plant tour. Between 9:40 AM – 1:45 PM, LPA conducted an interview with the Administrator, a staff, and five (5) out of five (5) residents. Continue on LIC 9099C Substantiated Staff does not ensure medications are properly stored. It was alleged that the facility left the keys in the medicine cabinet and unlocked medication in the refrigerator. On 01/06/2025 a credible witness conducted a visit to this facility and observed that the keys are left in the medicine cabinet and are not locked/secured. LPA conducted an interview with the Administrator who denied the allegation. Furthermore, during today’s visit LPA observed that the staff medications are unlocked in one of the kitchen cabinets and were accessible to residents in care. Additionally, LPA also observed that the key for the medication cabinet is visible and accessible in one of the kitchen drawers to residents in care. Based on credible witness and LPA’s observation during today’s visit this allegation is Substantiated. Staff does not ensure food is properly stored. It was alleged that the facility staff left food unsealed and open. On 01/06/2025 a credible witness conducted a visit to this facility and observed that food containers were left open. Additionally, on 03/10/2025, a credible witness conducted another visit and observed ice cream tub without a proper lid and a peanut butter jar open. LPA conducted an interview with the Administrator who confirmed that a peanut butter jar was open and unscrewed. Furthermore, during today’s visit LPA observed an ice cream tub open without a proper lid in the freezer. Based on credible witness, LPA’s observations during today’s visit, and the Administrator confirmation this allegation is Substantiated. Staff does not ensure expired/rotten food are disposed. It was alleged that the facility has expired/rotten food. On 01/06/2025 a credible witness conducted a visit to this facility and observed moldy tomatoes in the fridge. LPA conducted an interview with the Administrator who denied the allegation. However, during today’s visit LPA conducted a physical plant tour and observed wrinkled/aged chili peppers and expired milk with expiration date of 03/20/2025 in the refrigerator. Based on credible witness and LPA’s observations this allegation is Substantiated. Continue on LIC 9099C Staff does not ensure hazardous chemicals are properly stored. It was alleged that the facility left cleaning supplies in the cabinet under the sink unlocked and accessible to residents in care. On 01/06/2025, a credible witness conducted a visit to the facility and observed cleaning supplies unsecured and accessible. LPA conducted an interview with the Administrator who confirmed that the facility staff left laundry detergents unlocked and accessible to residents in care. Furthermore, during today’s visit, LPA conducted a physical plant tour of the facility and observed cleaning supplies unlocked and accessible under the bathroom sink to residents in care. Therefore, based on credible witness observation, Administrator interview, and LPA’s observation this allegation is Substantiated. Staff does not ensure dangerous items are properly stored. It was alleged that the facility staff left a knife on the kitchen counter and a lighter in an unsecured drawer. On 03/10/2025 a credible witness conducted a visit to this facility and observed unlocked knife and a lighter. LPA conducted an interview with the Administrator who denied the allegation. However, during today’s visit, LPA conducted a physical plant tour and observed a lighter in an unsecured kitchen drawer. Furthermore, LPA did not observe any knives or other sharp objects unlocked. Based on the credible witness and LPA’s observations this allegation is Substantiated. Deficiencies issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 31-AS-20250318150547

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 28, 2025

87309 Storage Space and Access: (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects..... pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on the credible witness and LPA's observation, the licensee did not comply with the section cited above in by leaving a lighter, a knife, and cleaning solutions accessible to residents in care which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator will properly train staff to keep cleaning agents and chemicals inaccessible to residents and proof of training will be sent to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Mar 28, 2025

87465 Incidental Medical & Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe & locked place… This requirement is not met as evidenced by: Based on the credible witness and LPA's observation, the licensee did not comply with the section cited above in by leaving medications unlocked and accessible to residents in care which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator agreed to schedule vendorized training for all staff by 03/28/25 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(28) · Plan of correction due date: Apr 3, 2025

87555(b)(28) General Food Service Requirements All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based credible witness and LPA's observations the Licensee did not comply by having old/rotten perishable foods and expired milk in the refrigerator which poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: The Administrator has agreed to remove and discard the rotten foods from the refrigerator. This part of the plan of correction met. Train all staff on food service and discarding rotten foods. Submit to CCL the staff sign in sheet and training material.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(15) · Plan of correction due date: Apr 3, 2025

General Food Service Requirements: The following food service requirements shall apply: 15) All persons engaged in food preparation and service shall observe personal hygiene and food services... ...which protect the food from contamination. This requirement is not met as evidence by Based on credible witness and LPA's observations the licensee did not comply with the section cited above by not properly securing the peanut butter jar and an ice cream tub which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator will have in service training for current and new staff regarding this section 87555. Copy of in service training will be submitted to LPA.

Type of visit: Required - 1 Year

An unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan on 11/01/2024 at 9:30 am. Upon arrival LPA met with Marasikova Damira, Caregiver, who granted access to the facility. LPA explained the reason for the visit. Shortly after the Facility Administrator, Marine Grigoryan arrived. LPA was informed that the facility currently has five (5) residents, of which two (2) residents are non-ambulatory. One (1) resident is on hospice and two (2) residents are receiving Home Health. Facility has waiver for 4 hospice residents. Resident Files: At 10:15am team conducted resident and staff records review. The following was observed. Five (5) out of 5 resident files were incomplete. Files were missing signed and completed Admissions agreements, Physician’s reports, resident preplacement appraisals/resident reappraisal, List of personal property, ID Emergency Sheets. Resident appraisals that were in the file did not have services explained and were missing signatures from the resident, and or responsible party. Please see LIC858 included with this report. Hospice and Home Health files are missing and or incomplete missing care plan, admissions, notes. Staff Files: The following was observed. There are no completed personnel records for all six (6) staff members which include the administrator. All files were missing personnel records (LIC501), Health Screening/TB results (LIC503), Documented medications and general training not completed. Please see LIC859 included with this report. With the assistance of the Licensee/administrator, a tour of the physical plant was initiated at approximately 11:00am and the following was observed: Continue on LIC809-C KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA found sufficient amount of two (2) days of perishable and seven (7) days of non-perishable food; emergency food was also stored inside the kitchen cabinets. LPA checked no expired food was found. Unsealed food was properly stored with labeled dates on them. LPA observed dining ware to accommodate a maximum capacity of six (6) residents. Knives and sharps were stored locked inside the kitchen cabinet. Kitchen chemicals and toxins are stored in the separate locket cabinet. Laundry machines are also located in the kitchen next to the staff bathroom and are always under supervision. COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. LPA observed puzzles, books, balls, and board games to provide activities to residents in care. Living room has fireplace, which is properly fenced and not accessible to residents in care. Facility has land line, LPA checked its operational. MEDICATION: LPA observed medication, staff/resident files, and First Aid kept inside the locked cabinet located office area near the kitchen. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program. LPA observed each centrally stored prescription and PRN medication has been logged in the medications log. Proper medication dispensing instruction are followed and checked for contamination. All medications are properly labeled and checked for expiration dates. BEDROOMS: There are four (4) bedrooms designated for residents’ use. All bedrooms are furnished and well equipped with beds, nightstand, chair, dresser, bedding, and extra linen. Rooms were observed to have sufficient lighting and closet space. Facility has awake staff. Extra towels and linens were readily available and nicely stored in the linen closet located in the hallway. Facility has 2 staff for AM shift and 1 awake caregiver for PM shift. Continue on LIC809-C BATHROOMS: The facility has three (3) bathrooms, bathroom #1 is located next to the kitchen and it is designated for staff use, bathroom #2 is located in the hallway next to the bedrooms #1, and bathroom #3 is located inside bedroom #4. All bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 11:20am to be at 118°F degrees. All trash cans in bathrooms had fitted lids to protect from cross contamination. SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 12:00pm they were tested and observed to be operational. The facility has one (1) new fire extinguishers that was purchased on 11/1/2024. The fire extinguisher is located in the hallway next to the kitchen. SURROUNDING GROUNDS: The backyard of the facility has sufficient yard space and it’s fenced. Exit areas are free of obstructions and hazards, exit gates were unlocked and easily accessible. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility has a swimming pool which is properly fenced and locked. There is no garage. The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. LPA collected LIC500, LIC9020, and Liability Insurance. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 1, 2024