Ash 1

Allegation investigated: Staff do not ensure that resident is taking medication as prescribed.

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced complaint visit. LPA was greeted by Staff # 1(S1) who contacted the licensee, Arlen Shahverdian. LPA explained the reason for the visit via telephone. Licensee met LPA shortly after. In the facility LPA observed three (3) out of five (5) residents and one (1) staff preparing medication. The investigation consisted of the following: A physical plant tour was conducted to ensure the health and safety of residents in care. LPA did not observe any health or safety concerns or issues. From 9:00 AM to 1:00 PM, LPA interviewed three (3) out of five (5) residents. Two (2) residents were not in the facility during time of visit. LPA interviewed S1 and the licensee. LPA requested and obtained copies of the following documents: Register of Facility Residents (LIC 9020), Personnel Report (LIC 500), residents' Physician's Report (LIC602), Appraisal Needs and Services, and Centrally Stored Medication records. LPA also reviewed residents' centrally stored medication and the facility's program. (Continue to LIC9099-C) Substantiated The investigation revealed the following: Regarding the allegation: Staff do not ensure that resident is taking medication as prescribed. It was alleged that morning medications are not administered properly. LPA's interview with two (2) out of three (3) residents present in the facility stated staff provide all medication prescribed. Interview with one (1) resident stated they have noticed the number of pills they are provided is different from one day to the next. They believe at least two medications have not be provided. LPA's review of the Centrally Stored Medication, Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR) revealed Resident #1(R1) had an alternative allergy medication prescribed with filled date 03/04/2026. LPA did not observe the medication documented on the MAR or CSMR. Review of the MAR revealed the originally prescribed medication was discontinued or no longer provided after 03/04/2026 without the new alternative medication being provided. R1 confirms they have not been provided the medication. LPA also observed an as needed or PRN medication with filled date 03/10/2026 was not documented in R1's MAR or CSMR. R1 confirmed they had not needed to request to take the PRN medication. The licensee stated they were not aware medication had changed or had been delivered and would immediately address the issue. S1 confirmed they have not provided the new medication. Based on LPAs observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. An exit interview was conducted, California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was given to administrator with the Appeal Rights. Regarding the allegation: Staff do not ensure that resident is provided comfortable living accommodations. It was alleged that resident(s) who smoke, are jeopardizing resident's health. LPA's review of the facility program only found that cigarettes should be kept inaccessible to clients with dementia and smoking is not mentioned in the program. According to the licensee nobody is allowed to smoke in the facility and the facility has a designated smoking area in the backyard. LPA's interview with two (2) out of three (3) residents present in the facility stated they smoke outside in a designated area and do not smoke indoors. Interview with one (1) of the three (3) residents stated although they have not witnessed residents smoking in the facility sometimes the door is slightly open and smoking residents are closer to the door then the designated area. Interview with S1 and the licensee deny anyone has smoked indoors and residents smoke in a designated area. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff yelled at resident. It was alleged that the licensee yelled at a resident. LPA's interview with two (2) out of three (3) residents present in the facility deny being yelled at by the licensee and deny witnessing the licensee yell at another resident. Interview with one (1) resident stated the licensee had yelled at them with a raised voice after dismissing their concerns. Interview with S1 and the licensee deny yelling at residents or witnessing another staff yell at residents. S1 states residents may yell at staff. Interview with the licensee revealed he had a conversation with Resident #1 (R1) but he never raised his voice and plainly stated to the resident that if they are truly unhappy nobody was forcing the resident to stay since they felt they were trying their best to accommodate the resident's requests. The licensee went on to say they are not sure if this was the incident the allegation was addressing but it was the only conversation that stood out to them. LPA was unable to find a witness to the licensee yelling at residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted. Copy of report provided to the administrator.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 31-AS-20260310162420

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 2, 2026

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met by: Based on the observations, interviews and record reviews, the licensee did not ensure R1 was provided their daily prescribed allergy medication which poses in potential Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: The licensee agreed to conduct in-service training with staff regarding medication. Licensee will provide LPA with a copy of the in service training sign in and material used to the department by POC due date 04/02/2026.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing inspection with both the applicant representative and administrator, Arlen Shahverdian and Ariga Mirzakhanian. An application to operate a Residential Care Facility for the Elderly was received by Community Care Licensing (CCL) on July 8, 2025. The fire clearance was approved on 07/17/2025 for six (6) non-ambulatory residents for a total capacity of six (06). A tour of the physical plant was initiated at approximately 9:45am and the following was observed: COMMON AREAS: These include the living room and dining room. The living room is furnished with sufficient seating, couches, and table. There is a fireplace that is secured with a screen. No fireplace tools present. The dining room table can accommodate the capacity. Common areas were observed free from any hazards. BEDROOMS: There are four (4) bedrooms designated for resident use. Bedroom #1 and #2 are shared rooms. Bedroom #3 and #4 are private. The resident bedrooms are furnished with beds, night stand, chairs, chest of drawers, bedding and linen. The bedrooms have sufficient lighting and closet space. Passageways and exits from each bedroom are free and clear of any obstruction. The smoke alarms and carbon monoxide detector are dual, hard wired and inter-connected. The facility has one fire extinguisher, located at the kitchen/dining room area. The fire extinguisher was purchased on June 11, 2025. (Continue to LIC809) BATHROOMS: The facility has two (2) bathrooms. Bedroom #1 has it's own private bathroom with shower. The second bathroom, is located in the hallway by the other resident bedrooms. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid flooring. The hot water temperature was test in the hallway bathroom and measured 113.4 degrees Fahrenheit. KITCHEN: The kitchen area is equipped with a refrigerator, stove/oven, dishwasher, microwave and sink. At this time, perishable food items are not required as there are zero (0) residents. There is an adequate supply of nonperishable and emergency food stored in the garage. There is also sufficient dining ware to accommodate the capacity of the facility. Knives and sharps were observed locked in a kitchen drawer. LAUNDRY ROOM / GARAGE: The laundry room is equipped with a washer and dryer. The laundry room is able to lock making inaccessible to residents. Detergents, and cleaning supplies will be stored locked in a cabinet above the washer and dryer. There is an attached garage, accessible through the laundry room. OUTSIDE: The backyard is entirely fenced in. There is a detached garage and shed used for storage. No bodies of water observed. There is sufficient space for outdoor activities. MEDICATIONS / RECORDS: Medications and records will be stored in a closet the kitchen and laundry room. Closet will be able to lock. First aid kit and manual will be maintained in the medication closet. Component III was conducted with the Licensee representative and the Administrator. Pre-Licensing is complete, and this facility has no deficiencies. This report will be sent to Centralized Application Bureau (CAB). You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. Copy of this report provided.the state’s words, verbatim · CDSS document, Oct 22, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.