Amore Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection of the facility. LPA met caregiver Mary Aslanyan and explained the reason for the visit. The current census is (1). Administrator Mariya Melonyan was contacted over the phone, and she was also informed the reason of the visit. A tour of the physical plant of the inside and outside was conducted. Kitchen: The kitchen was clean and the appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; and properly stored. Knives and detergents were stored in locked drawers and cabinets. Properly labeled medications were locked in a cabinet near the kitchen. Bedrooms: There (3) bedrooms designated for residents. All bedrooms were properly furnished, with bedding and linens, as well as sufficient lighting. Bathroom: There were two bathrooms. Both bathrooms properly supplied with soap and towels, as well as functional fixtures; including grab bars. Hot water temperature 107.4 degrees Fahrenheit. Common Areas: These included the living room and dining area: all areas were clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards, with furniture for clients. There is no a swimming pool in the backyard. Storage shed kept for extra supplies. All smoke alarms were tested and operating properly. The fire extinguisher was fully charged. First aide had Licensing requirements. Resident/Staff records inspected: All required documents observed in files. Medication was observed to be inaccessible and stored in a secured cabinet. There were no errors observed. No citations or deficiencies observed during visit. Exit interview and copy of report provided to caregiver.the state’s words, verbatim · CDSS document, Sep 2, 2025

Allegation investigated: Resident records were not readily available to emergency medical personnel.

Licensing Program Analysts LPA Leizl de la Cerra conducted an unannounced visit for the above noted allegation. LPA was greeted with staff caregiver, Mariana and explained the reason for the visit. Facility Administrator/Licensee, Mariya Melkonyan was contacted and arrived shortly. It was reported that on September 2, 2024, 911 was called, and emergency personnel responded to the above address for a reported resident (R1), who was unresponsive. EMTs and fire technicians arrived on scene and the facility staff #1 (S1) was unable to produce any records regarding R1's demographics, medical history, or medical wishes. During resuscitative efforts, staff did not produce an Advanced Care Directive, (DNR or Power of Attorney). The records were provided by another staff who arrived at the facility after resuscitation effort ended and R1 was determined dead. CONTINUED to LIC9099C Substantiated To investigate this complaint, LPA requested copies of facility documents relevant to the investigation at 12pm, records included but not limited to residents’ and staff roster, and R1’s facility file, including but not limited to R1’s identification information, Physician report, advanced directives, DNR, and other records. LPA de la Cerra reviewed the file between 12:30pm and 1:00pm. Staff interviews were initiated between 12:00pm and 12:30pm. A Review of R1’s resident file revealed that R1 has a signed advance directive, DNR – Do Not Resuscitate, a form previously requested by the emergency personnel. Staff interviews confirmed that S1 did not have R1’s file readily available for emergency personnel. Based on inspection, observation, interviews and record reviews, there is sufficient information to support the allegation. Therefore, the allegation is substantiated at this time. Per CA Code of Regulations, Title 22 Division 6, Chapter 8, the following deficiency was cited and recorded on LIC9099-D. During this investigation, LPA noted other Title 22 Deficiencies. Therefore, Case Management visit was conducted in conjunction with complaint investigation to address other deficiencies unrelated to the complaint. Exit interview was conducted, appeal rights discussed, and a copy of report was issued to facilitythe state’s words, verbatim · CDSS document, Sep 10, 2024 · control 31-AS-20240903145023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(1) · Plan of correction due date: Sep 24, 2024

87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and... on file experiences a medical emergency, facility staff shall...(1) Immediately telephone911, present the advance directive form to the responding emergency medical personnel & identify the resident as the person to whom the order refers. This requirement is not met as evidenced by, Staff failed to immediately provide advanced directive to the responding emergency medical personnel.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: Administrator will submit written statement explaining how the facility will follow the implemented policy and procedures on responding to emergency with DNR on file at the facility. Administrator will provide training to ensure cited deficiency does not reoccur. A written statement will need to be submitted to CCL/LPA by POC date.

Type of visit: Case Management - Other

This Case Management visit is conducted in conjunction with complaint investigation visit today. (Complaint 31-AS-20240903145023). The purpose of this Case Management visit is to address the deficiencies that were observed during the complaint investigation not related to the complaint. LPA de la Cerra was greeted by the staff #1 (S1) who identified herself as a caregiver for the facility. LPA explained the reason for the visit and requested the caregiver to inform the administrator about the visit. S1 provided their name and LPA de la Cerra noted that S1 did not have a criminal record clearance and association to the facility. By allowing an individual who had no criminal record clearance and/or association to the facility, to be present and work for the facility.The licensee is in violation of CCR 87355(f)(1). Therefore, the deficiency will be cited under Title 22, Division 6, Chapter 8, and will be recorded on LIC809D. In addition a civil penalty of (the amount) will be issued. No other immediate health and safety hazard is noted during this visit. Exit interview was conducted, appeal rights discussed. The report was signed by the administrator, and copy of report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(f)(1) · Plan of correction due date: Sep 11, 2024

Criminal Clearance (f) Violation of Sec. 87355(e) shall result in an immediate... civil penalties(1)Subsequent violations within a twelve (12) mo. period will result in a civil penalty ($100)a day for a max of thirty 30 days.This requirement is not met as evidenced by Based on interview and record review, the licensee did not comply with the section cited above by hiring one (1) staff member on without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: LPA requested admin to remove S1 from facility asap. Within 24 hours licensee must inform RO that S1 is removed and will not return to facility without criminal record clearance & association. Licensee will submit S1's fingerprints and associate the staff to the facility. Copy of proof will be submitted to LPA within 24 hours. Civil penalty assessed.

Allegation investigated: Staff left resident unattended. Staff did not arrange proper transportion for emergency medical services.

On 09/03/24 Licensing Program Analyst (LPA) Leizl de la Cerra conducted a subsequent unannounced visit and was greeted by caregiver, Kristina Melkonyan. LPA stated the purpose of the visit. The administrator was on the phone and informed LPA that they were unavailable and gave consent to the caregiver to sign the report.At approximately 11:00am, LPA de la Cerra conducted a tour of the facility and LPA conducted interviews with the staff and the resident present at the facility Allegation: Staff left resident unattended. To investigate the allegation LPA conducted interview with caregiver, S1. It is alleged that a staff member from the facility did not attend to R1 by placing R1 in an UBER rideshare without a staff member accompanying R1 in the UBER rideshare transportation. Interview with S1 confirm that residents have never been left unattended inside or outside the facility. R1 interview confirmed that R1 has never been left unattended inside or outside the facility. Furthermore, neither resident nor administrator have any knowledge of who the unattended individual, R1 is. Based on overall investigation it was concluded that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, is deemed UNFOUNDED at this time. -CONTINUED TO LIC9099-C Unfounded Allegation: Staff did not arrange proper transportation for emergency medical services. To investigate the allegation LPA conducted interviews with one (1) out of one (1) resident who is present at the facility. LPA interviewed administrator, S1. It is alleged that a staff member from the facility placed R1 in a UBER rideshare transportation which is not a medically equipped vehicle to transport R1 to Olive View Emergency Room, Interviews with one (1) resident and one (1) staff was confirmed that UBER rideshare is not the proper form of transportation used for emergency medical services. Furthermore, neither resident nor staff member does not have any knowledge of any individual from the facility transported to Olive View Emergency by UBER rideshare. Based on overall investigation it was concluded that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, is deemed UNFOUNDED at this time. This agency had investigated the complaints and we have found that the complaints were without a reasonable basis. We have therefore dismissed the complaints. LPA did not observe any health and safety issues. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 3, 2024 · control 31-AS-20240517144753

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Ruzanna Gevorgyan for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:00 AM and the following was noted: There is one entrance being utilized at the facility. The facility has a total of three (03) bedrooms for residents and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory of which two (02) may be bedridden and a hospice waiver for six (06). The facility is currently occupying two (02) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 77°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the foyer, observed to be fully charged and last purchased on 11/24/2023. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 112.4°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 18, 2024

Type of visit: Required - 1 Year

On 11/13/2023 at 09:30 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Asst. Administrator Asya Akopyana. Two (2) residents and One (1) staff were present during this inspection. Facility is licensed to serve six (6) non-ambulatory residents, two (2) may be bedridden in any room. The facility also has an approved hospice waiver for six (6) residents. The facility currently has (One) 1 non-ambulatory resident. Two (2) residents receive Hospice services, and one (1) resident is receiving Home Health Services. The Annual Licensing Fees are current. Required postings were observed in the entry area. The home consists of 1 floor level with: 1 staff room, 3 resident rooms, 2 restrooms, kitchen, dining room, and laundry room. The assistant administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. All windows have screens and Alarms due to Dementia residents. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. The middle bathroom hot water temperature properly measured between 117.8-118.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. (Contd from 809) LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Properly stored between two refrigerators across from each other. Knives and toxics were kept in a locked storage cabinet. First Aid kit was available stored next to medication. One fire extinguisher, last serviced November 13, 2023, was observed in the kitchen area second fire extinguisher was observed in the entryway. LPA tested all carbon monoxide detectors and smoke detector located in the kitchen area. Both devices were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector. Two (2) staff records were reviewed, 2 out of 2 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Two (2) resident records were reviewed and 2 out of 2 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans, and CSMD Medication and Medication Records were reviewed for proper documentation. An exit interview was conducted, A copy of this report and appeal rights were discussed and left with Assistant Administrator Asya Akopyana.the state’s words, verbatim · CDSS document, Nov 13, 2023