My Home Facility

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required- 1 year visit. LPA met with Lyudmila Tavmasyan, Care staff and explained the purpose of the visit. The administrator Hasmik Nshanyan was called on the phone to inform of the visit and arrived at 11:00am, to assist LPA. The facility is approved to serve residents age range 60 and over, approved for capacity of (6) residents of which (1) may be bedridden. Bedroom #1 cleared for bedridden and approved hospice waiver for (6) hospice residents. Compliance and Regulatory Enforcement (CARE) tool was not utilized during the visit as it is not available for the annual/random type of visit. The facility has submitted the Infection Control Plan and was last reviewed/updated by the administrator on May 1, 2026. Facility has a valid Liability Insurance, expires on July 12, 2027. Fire drill was last conducted on 07/15/2026. The facility is a single story home consists of (5) resident bedrooms, (2 1/2) bathrooms, kitchen, dining room, living room with covered fireplace, laundry area, attached garage, backyard with gated swimming pool and covered patio. Resident bedrooms were toured and each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Knives, sharps are locked in the kitchen drawer and inaccessible to residents. Cleaning solutions and disinfectants are stored under the kitchen sink cabinet, locked and inaccessible to residents. In the attached garage, LPA observed a gallon of bleach and other cleaning supplies stored next to food items such as oatmeal and boxes of cereals. At 10:46am, hot water temperature was measured, at 115.3 deg F in bathroom #1 and 116.2 deg F in bathroom #2 which is within the Title 22 regulations. Exit doors are free of any obstruction. Backyard was inspected and it has a covered sitting area and a gated swimming pool. Fire extinguisher was observed mounted on the wall next to the kitchen, purchased on 11/06/2024. Administrator purchased a new fire extinguisher during the visit. Fire drill was last conducted on 01/17/2026. *****Refer to LIC 809C for the continuation of this report. ***** A total of (6) staff members including the Administrator provide care and supervision to the residents. There is a night staff person awake and on duty.Staff employed are over the age of 18, have training and associated to the facility. Administrator's certificate is valid and expires on 09/03/2026. LPA reviewed (3) staff files including the administrator. Proof of staff training and health clearance are current. Resident personal rights are posted. Facility provides internet service and phone to the residents. LPA reviewed (4) resident files. Resident files are maintained in the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent for Medical Treatment, Resident Personal Property and Residents Personal Rights observed. There is sufficient space to accommodate both indoor and outdoor activities. There are sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. LPA observed the food stored in covered plastic containers in the refrigerator are not labeled and a gallon of milk expired (2) days ago, Aug. 26, 2026. LPA also observed a bottle of dietary supplement/vitamins (Airborne gummies for adults) stored with canned goods and other food supplies. There are no residents with special diets residing at this facility. LPA reviewed residents' medications. The medications are centrally stored and in their original containers. All medications are labeled and are maintained in compliance with label instructions. Medications are administered as prescribed by the Physician. Emergency and Disaster Plan is in place, was reviewed and updated on 11/20/2025. Administrator updated the temporary shelter location/information during the visit. There are (0) hospice and (0) bedridden residents. There are no residents with prohibited health conditions. Deficiency cited and Technical advisories issued. Exit interview and a copy of this report was provided to Hasmik Nshanyan, Administrator.the state’s words, verbatim · CDSS document, Aug 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Sep 4, 2026

1569.695 Emergency Plans..(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill.... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Based on record review, the facility conducted the last fire drill on 01/17/2026 but should be conducted at least quarterly and fire drill logs as required. which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: The administrator will ensure that emergency drill is conducted at least quarterly for each shift. Administrator will submit signed self certification that she read, reviewed & understood HSC1569.695 along with an in-service training emergency drill log. Administrator agreed to submit all the required proof of corrections to LPA/CCLD by POC due date.

Allegation investigated: Staff not transporting resident(s) to scheduled appointments. Staff yell at residents. Lack of supervision resulting in resident being physically assaulted by another resident. Staff do not assist resident. Staff do not prevent resident from disturbing another resident sleep.. Staff do not administer residents medications as prescribed. Staff do not allow residents access to available bathroom. Facility is not providing adequate food service for residents.

At 09:00am, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi conducted an unannounced visit in response to the above-mentioned allegations. LPAs met with the Administrator and explained the reason for the visit. At 09:05am, LPAs requested residents and staff roster. At 09:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Centrally Stored Medication and Destruction Record (CSMR), Medication Administration Record (MAR), Menu and Staff Training relevant to the investigation. At approximately 09:15am, LPA conducted a physical plant tour. Between 09:20am – 11:00am, LPA conducted an interview with the Administrator, two (2) staff, and four (4) out of six (6) residents, who were able to communicate. Continue on LIC9099-C Unsubstantiated Allegation: Staff not transporting resident(s) to scheduled appointments. It was alleged that facility staff are not transporting R1 to their scheduled appointments. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that R1 was transferred to this facility from Santa Barbara County and R1’s insurance was not transferable from county to county. In order for R1 to be seen by a doctor in Los Angeles County, the Administrator took R1 to Social Security Administration Office on 02/25/25. However, the representative was unable to assist and scheduled an appointment for 03/17/26. In a meanwhile, the Administrator contacted the Sanctuary Centers of Santa Barbara (CSB) and requested a zoom appointment for R1. The request was granted and the appointment was scheduled for 03/09/2026 at 2:00pm. LPA was informed that right before the telephonic visit, R1 informed the Administrator that he/she does not wish to attend the appointment and refused to connect to the zoom. LPA contacted the CSB and confirmed that due to R1’s refusal the appointment was canceled/rescheduled. Moreover, LPAs were informed that on 02/27/26 R1 was taken do Dr's office for a blood test, however, the doctor's office informed that the lab test must be done through Quest Diagnostics. S2 immediately drove to the Quest, but R1 refused to get out of the car. The following appointment was scheduled for 03/02/26, however, the blood test was again canceled due to the lack of R1's valid Identification. During today’s visit, LPAs also conducted interviews with three (4) residents and was informed that the staff always arranges and or provides transportation for all their doctor’s appointments. Three (3) residents interviewed expressed no concern regarding this allegation. Therefore, based on interviews and record reviews, this allegation is deemed Unsubstantiated, at this time. Allegation: Staff yell at residents. It was alleged that R1 asked for toilet paper and S1 got mad and yelled at R1. To investigate this allegation LPAs conducted an interview with the Administrator and two (2) staff members and all parties interviewed denied the above allegation. LPAs were informed that every morning and evening the staff conduct round checks to make sure all toilet supplies are intact and available for residents’ use. Three (3) out of four (4) residents interviewed expressed no concern regarding this allegation and confirmed that staff communicate appropriately. Residents reported that it is R1 who yells and causes disturbances, not staff. During today’s visit LPAs observed staff treating residents in a professional and respectful manner. Therefore, based on interviews and LPAs observation, this allegation is deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Lack of supervision resulting in resident being physically assaulted by another resident. It was alleged that R1 was physically assaulted by a R2. It was also reported that R2 grabbed R1 by his/her neck and hair. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that R2 had been living at this facility for over one (1) year. During R2’s entire stay the Administrator did not observe R2 being physically and or verbally aggressive towards other residents/staff. However, R1 was admitted to this facility on 02/02/26, and showed numerous aggressive behaviors towards the residents and staff. Administrator also informed LPAs that the facility staff being aware of R1’s aggressive behavior always keep an eye on R1, so that they can immediately de-escalate the situation, if any. Administrator stated: “Due to R1’s mental status, R1 is not suitable for this facility. I also had a discussion with R1’s Case Worker who informed me that they will actively look for an alternative placement. I will have to issue an eviction letter to R1 today.” Furthermore, during the interview with S1, LPAs were informed that an incident occurred on 03/09/26, around 5:00pm. S1 stated that they were talking to R2 by the kitchen area, and R1 came out from his/her room, already looking aggressive, and pushed S1 against the wall and attacked R2. R2 asked R1 to back up and stay away from them. R2 also informed R1 that they will call 911 and press charges against them. Although two (2) officers responded to 911 call, no police report was filed due to both parties (R1 and R2) wanting to press charge against each other. Officers advised both residents to file restraining orders through the court and stay away from each other. Interview with three (3) residents confirmed the statement provided by the Administrator and S1 and all residents interviewed denied that "lack of supervision" was a factor in the incident. LPAs were informed that the staff is always available and provided excellent supervision and protect residents from being physically/verbally assaulted. Lastly, LPA conducted review of the Incident Reports and observed that the facility did submit a written incident to the Regional Office in a timely manner. Therefore, based on interviews and record reviews this allegation is deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Staff do not assist resident. It was alleged that facility staff do not assist residents when assistance is requested. To investigate this allegation, LPAs conducted an interview with the Administrator, S1 and S2 and all parties interviewed denied the above allegation and stated that staff respond promptly when residents call. Staff explained that residents who require additional attention are immediately attended to, and assistance is provided continuously throughout the day and night. Three (3) out of four (4) residents confirmed that staff provide assistance as requested. Residents reported that R1’s behavior sometimes disrupts care delivery but did not indicate that staff refuse or fail to assist other residents. Therefore, based on interviews this allegation is deemed Unsubstantiated, at this time. Allegation: Staff do not prevent resident from disturbing another resident sleep. It was alleged that staff do not prevent residents from disturbing R1 during sleep hours. To investigate this allegation LPAs conducted interviews with the Administrator, S1 and S2 and all parties interviewed denied the above allegation and stated that five (5) out of six (6) residents have been living at this facility for over one (1) year and they never had any complaints regarding residents disturbing each others sleep. However, R1 moved to this facility on 02/02/26 and every morning, around 5am, R1 speaks very loudly and knocks on every residents' door. Staff is always available to redirect and calm R1 down, however, R1 occasionally creates noise due to their mental diagnosis. During today's entire visit, LPAs observed R1 walking from door-to-door to make sure that all residents are in their rooms. LPAs observed that R1 continuously disturbing residents privacy and the staff provides redirection. Therefore, based on interviews and LPAs observation, this allegation is deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Staff do not administer residents medications as prescribed. It was alleged that staff do not administer medications as prescribed. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that the staff had been properly trained on medication administration and always assist residents with their medications as prescribed. Interview with S1 and S2 confirmed the statement provided by the Administrator and informed LPAs that all medications are properly documented. LPAs conducted review of three (3) random medications for R1 and R2. LPAs also counted the medications and compared to CSMDR and MAR and observed no discrepancy. Lastly, three (3) out of four (4) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews, record reviews and medication count, this allegation is deemed Unsubstantiated, at this time. Allegation: Staff do not allow residents access to available bathroom. It was alleged that multiple residents are waiting in line to use the bathroom because staff does not allow residents access to available bathroom. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that the facility has three (3) bathrooms, of which one (1) is in room #2 (master bedroom) for R2 use only. The second bathroom is located by bedroom #4 and is available for all residents and the third bathroom ("staff only"). LPAs were also informed that three (3) out of six (6) residents do not use bathrooms due to incontinence. R1 and R3 have shared bathroom available for use, however, if necessary, the staff will allow them to also use the "staff bathroom". Three (3) out of four (4) residents interviewed expressed no concern regarding this allegation. LPAs were informed that they are able to go to the bathroom on their own and never had to "wait in line." During today's visit, LPAs did not observe residents being denied access to bathrooms. Based on interviews and LPAs observation this allegation is deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Facility is not providing adequate food service for residents. Staff are not providing adequate food service to residents in care. It is being alleged that the food portions are small, and that staff are not meeting R1’s dietary needs. LPAs interviewed three (3) out of four (4) residents, who were able to communicate and were informed that the food portions are sometimes small but they can ask for more. All residents interviewed stated that food choices are sufficient and there is always fruit, vegetables and alternative choices available daily. Staff stated that food quality and portions are good and balanced. Facility provides three meals, which includes vegetables, fruits, salad and dessert with a secondary menu for residents who do not like the meal of the day, as additional options. Residents may ask for more food, which is provided throughout the day/night. Residents can notify the caregivers of their food preferences, if they don't like the food of the day and the staff will prepare a different meal for them. During todays visit, LPAs observed balanced/nutritious lunch being served to six (6) residents, which include: vegetable soup with noodles, ham sandwich with cheese, lettuce, tomato and avocado, along with cookies and bowl for fruits. LPAs were also informed that R4's meals are prepared based on physician's instructions and the staff follows R4's dietary needs. LPAs observed sufficient supply of perishable (2 days) and non-perishable (7 days) food items in the pantries, refrigerators and freezers. LPAs obtained copy of facility's three (3) week menu in which a diet for residents with meat or vegetable preference can be observed. Based on interviews and LPAs observation this allegation is deemed Unsubstantiated, at this time.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 31-AS-20260309151025

Allegation investigated: Staff are not treating residents with dignity and respect. Staff leave residents soiled for extended periods of time. Residents do not receive adequate recreation time. Staff are not meeting residents needs.

On 2/26/2026 at approximately 9:20 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. The Administrator, Hasmik Nshanyan arrived shortly after to assist with today’s visit. To investigate the allegation(s), at approximately 09:30 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation. From 10:00 AM to 12:30 PM, LPA attempted interviews with six (6) residents (R1-R6), two (2) staff members (S1-S2) and conducted record review. (Contintue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff are not treating residents with dignity and respect. It was alleged that S2 has yelled at residents and speaks to them in an inappropriate manner. To investigate the allegation, LPA attempted interviews with six (6) residents and two (2) staff members. LPA’s interview with R1 regarding the allegations pertaining to S2 resulted in contradicting statements such as them stating S2, “Barks” at them but then would immediately follow-up by saying S2 was “Nice” to them. LPA’s interview with R2 and R3 revealed that staff do not yell at them or treat them in a disrespectful manner. R3 stated S2, “Speaks loud but is not yelling” at them. LPA attempted to interview R4-R6 but due to their inability to validate the questions being asked, LPA terminated the interviews. LPA’s interview with S1 revealed that S2 has never yelled at residents. LPA attempted to interview S2, but they were not present during LPA’s visit. During LPA’s physical plant tour, LPA observed staff assisting residents. LPA did not observe any staff yelling at residents. LPA did not observe residents to display any characteristics of being fearful of staff. LPA observed residents interacting with one another including staff. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff leave residents soiled for extended periods of time. It was alleged that R6 is left in their soiled diaper for an extended period of time. To investigate the allegation, LPA conducted interviews with two (2) residents and one (1) staff member. LPA’s interview with both residents revealed that staff do not leave residents soiled in their diapers for extended periods of time but that residents such as R6 will decline to be changed. LPA’s interview with S1 confirmed, R6 can be difficult at times to change due to their cognitive diagnosis but staff are trained to redirect and attempt again. During LPA’s physical plant tour, LPA observed R6 to be interacting with both staff and residents. LPA did not observe R6 or other residents to omit foul odors such as urine. LPA did not observe R6 to be wet. LPA observed R6 to be well dressed and groomed appropriately. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Residents do not receive adequate recreation time. It was alleged residents are not being provided with recreational activities. To investigate the allegations, LPA conducted interviews with two (2) residents and one (1) staff member. LPA’s interviews with both residents revealed that they are provided with recreational activities such as going on walks. LPA’s interview with S1 revealed that residents are provided with board games such as bingo in addition to other activities. Upon LPA’s arrival, LPA observed an arts and craft table to display drawings done by the residents. During LPA’s physical plant tour, LPA observed additional activities such as bingo and board games available for residents use. LPA observed sufficient seating in the backyard of the facility with a shaded area. LPA observed residents to be using the outside shaded area. Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not meeting residents’ needs. It was alleged that staff are not meeting residents’ needs such as quality of food. To investigate the allegation, LPA conducted interviews with three (3) residents and one (1) staff member. LPA’s interview with R1 revealed that they became ill, including R2, when they consumed food provided to them. R1 could not provide LPA with an exact date of when said event occurred. LPA’s interview with R2 and R3 revealed that their needs are being met. When LPA questioned if they were ever served food within the facility that caused them or others to become sick, both residents denied such allegations. LPA’s interview with S1 confirmed both residents’ interviews. During LPA’s physical plant tour, LPA observed residents to be served variety of food of good quality. LPA did not observe any of the food to appear molded. LPA observed staff to be cooking and cleaning. LPA observed residents eating the food being served without any residents complaining of feeling sick after consumption. Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 31-AS-20260217155720

Type of visit: Required - 1 Year

At 9:00am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Staff #1, who granted access to the facility. Administrator arrived shortly after, and LPA explained the reason for the visit. At 9:10am LPA conducted a physical plant tour and observed the following: Facility is licensed for capacity of five (5) Non-Ambulatory of which one (1) may be Bedridden in room #1. Hospice waiver for six (6) residents is also approved. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. The fire extinguisher is located in the kitchen area and was last serviced on 11/06/2024. Facility maintains a temperature of 71°F. Medications, resident/staff files were kept in the kitchen cabinet and observed to be locked and inaccessible to residents in care. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. There are four (4) bedrooms designated for residents’ use. Facility has an awake staff. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 106.3°F. Laundry is located in a hallway, by the garage, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. The washer/dryer appear to be in a good condition. Continue on LIC809-C Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:15am they were tested and observed to be operational. At 10:20am, LPA observed appropriate outdoor furniture, with a covered shaded area for the residents. There is a swimming pool that is fenced with a gate that will be kept locked at all times. The fence installed to keep residents out of the swimming pool area is approximately 5 feet high throughout the parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. Between 10:40am to 12:00pm, LPA reviewed records of four (4) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians. LPA collected Certificate of Liability Insurance and LIC500. The annual license fee paid in full on 03/31/25. No deficiency cited during today's visit. Exit interview conducted and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Required - 1 Year

At 12:25am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with Staff #1, who granted access to the facility. LPAs explained the reason for the visit. At 12:45am LPA conducted a tour of the physical plant and observed the following: Facility is licensed for capacity of six (6) of which five (5) may be Non-Ambulatory and one (1) bedridden residents. Facility also has a hospice waiver for six (6) residents. There are four (4) bedrooms designated for residents use, and one (1) bedroom is designated for a live-in caregivers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. During the LPAs did not observe any immediate health and safety concerns. Facility maintains a temperature of 73°F. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. The fire extinguisher was observed to be fully charged and was located in the kitchen area. Laundry is located in a hallway, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. LPA observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Smoke detectors and carbon monoxide monitors were tested at 12:00pm and observed to be functional. Between 12:30am to 2:00pm, LPA reviewed records of five (5) clients and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500. No citations issued during this visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 7, 2024