Breath of Sunshine Plus

Type of visit: Required - 1 Year

On 10/28/2025 at 8:15AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with Aida Dzhumakanova, Caregiver. Ruzanna Simonian, Administrator was called and arrived shortly after. LPA asked for the census, staff and resident files. The physical plant was toured at 9:15am. Living/Dining Room Area: LPA Saucedo observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 72 degrees Fahrenheit. The dining/living room area is big enough and has enough seating for staff and residents. Bedrooms/Bathrooms: There are four (4) bedrooms. All four (4) bedrooms are used for residents. There are two (2) bathrooms. Two (2) rooms are shared and two (2) rooms are single, occupied. In the hallway, there is a closet that has extra linen. LPA observed the bedrooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the resident’s room. The hot water temperatures were measured within regulations of 118 degrees. The showers have non-slip bathmats and grab bars. There is also a signal system in the facility. There is a one (1) fire extinguisher fully charged and is dated August 2025. Medications are locked and inaccessible to residents in a black cabinet in the office area. All medications were properly labeled and inaccessible to residents. LIC809C-continued Kitchen Area: LPA inspected the kitchen area. There is one (1) refrigerator which was clean and in good operation in this area. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinets. The knives/sharps were locked and inaccessible to the residents on your left-hand side. The toxins/chemicals are kept under the sink area locked and inaccessible to the residents. Garage: The washer and dryer are kept in the garage area. The garage is detached from the house and is used as a storage. Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility does not have a pool and/or bodies of water. The carbon monoxide and the smoke detector were tested, and they were operable, interconnected. There is a signal system. There are cameras in the common areas. Administration: The Liability Insurance was reviewed and will be renewed on 11/14/2025. There are several signs such as Emergency Disaster Plan, Personal Rights, Theft and Loss Policy, Family Council, Bill of Right in the office area. The Ombudsman sign is located by the entrance of the facility and the YES sign. The last fire drill that was conducted was on 10/15/25. Staff/Resident Files: Six (6) resident files were reviewed and three (3) staff files were reviewed. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2025

Type of visit: Prelicensing

On 11/4/24, at 09:45am, Licensing Program Analysts (LPAs) Angelica Segovia and Gina Saucedo conducted an announced Pre-licensing visit. LPA's met with Administrator Ruzanna Simonian at 9:45 am. An application was submitted to Community Care Licensing Division-CCLD on 07/15/2024, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The requested capacity is for six (6) non-ambulatory and one (1) may be bedridden, total of up to six (6) residents and fire clearance was approved on 8/20/2024-Room number three (3) is for bedridden. Structure: The facility is a single-story building with four (4) bedrooms and two (2) bathrooms. Entrance: There is only one (1) entrance being utilized. Required postings such as: Personal Rights of Residents, Rights of Resident by Council, Family Council, Infection Control, Emergency and Disaster Plan, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy and YES are posted along hallway leading to bedrooms. Toxins, cleaning solutions, and laundry detergents are kept locked under the sink in the kitchen inaccessible to residents. Living/Dining area: The living room is neat, clean, and organized with sufficient seating for both residents and staff. The dining area is also neat, clean, and organized. Both rooms are properly furnished and in good repair. The facility maintains a comfortable temperature of seventy (70) degrees. No firearms observed or will be maintained on the premises. Resident/staff files: Resident and staff files will be kept locked in filing cabinet in office through the passageway hallways inaccessible to residents. LIC809C-continued Kitchen: Sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. Sharps are stored on the left side of the kitchen locked and inaccessible to the residents. Sufficient supply of food such as: canned goods, bottles of water, cereal were observed in the garage. Kitchen appliances are working and are in good repair. First-aid kit observed as well. There is a working telephone on the premises. Emergency: Fire extinguisher located in the kitchen on the right side and dated 7/20/2024. Medications: Medication will be stored both in a kitchen cabinet and filing cabinet in the office. Daily medication will be kept in kitchen cabinet locked. Monthly medication will be stored in filing cabinet within the office. Medication storage is equipped with a lock to ensure medications will not be accessible to clients. Bedrooms: The bedrooms are properly furnished with bed, nightstand, applicable lightening, and seating. Window coverings are in good repair, not broken or damaged. Bathroom: The bathrooms are in proper condition and will be equipped with sufficient personal hygiene for each client. Towels and washcloths will not be shared. Hallways: Hallway is properly lighted. Extra linens/covers observed in storage cabinet within the passageway. Staff room: there is no designated staff room in the facility. Water Temperature: The water temperature was measured in the bathrooms at 118.8 Fahrenheit and is within regulations. LIC809C-continued Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested. Garage: The garage is located outside separate from the facility and is currently being utilized for storage, emergency food, and Laundry. Dryer and washer observed to be in good repair. The garage has a half bathroom for staff use only. Outside: The outside is clean, free of hazards, and will be properly furnished with sufficient seating. A shaded area for residents was observed as well. Pool: no bodies of water located at the facility. Administration: The facility had submitted an Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan. The Component III Orientation RCFE was shown/reviewed with the Administrator. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview conducted and copy of this report issued to the administrator.the state’s words, verbatim · CDSS document, Nov 4, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Method: Telephone call with CAB COMP II Participants: Simonian, Ruzanna & Simonyan, Armen On 10/29/24, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 29, 2024