A-1 Boarding Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced Annual Inspection visit and used the CARE inspection Tool to conduct the visit. LPA Yee was let into the home by Ani Malkhasyan, Staff. Erna Gevorgyan, Administrator designee was conducted by telephone and she arrived at 11:06am to conduct the visit. The reason for today's visit was provided. The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 4 bedrooms, 2 private bathrooms and a common bathroom. Located in the back of the property is an ADU with a separate address - 6509 Bonner Avenue, and is not part of the facility operations. The facility is fire cleared for 1 AMBULATORY, 4 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #2 or Bedroom #3 approved for 1 bedridden use. The facility is approved for 6 hospice waivers. On today's visit, the entire CARE Inspection tool was reviewed, 6 resident and 6 staff files were reviewed and the Emergency Disaster Preparedness Plan was reviewed. The following was observed: Bedrooms #1 and Bedroom #2 are furnished with 2 beds, 2 night stands, 2 lamps, 2 chairs and a built in closet. No dressers were observed. The left bed in bedroom #2 was equipped with a full bed rail due to resident previously on hospice but has since being discharged and the right bed equipped with a half bed rail. Bed rails need to be removed. There is no physicians order for the use of the bed rails. Bedroom #3 is furnished with 2 beds, 2 chairs, 2 lamps, 2 night stands, 1 built in closet and a shared dresser. The wall needs to be painted due to the resident peeling off the paint each time it is painted. continued on LIC809-C Page 2. Located inside Bedroom #3 is a private bathroom, equipped with a walk in shower, a toilet and a sink. Grab bars were observed. No slip resistant mat was observed. Water temperature was tested and read 116.5 degrees Fahrenheit. Bedroom #4 is currently not furnished and is used for storage. Located inside is a private bathroom equipped with a shower stall, a toilet and a sink. Grab bars were observed. No slip resistant mats were observed. the living room and dining room were furnished with the appropriate furniture for it's designated use. Extra bed linens and towels were observed in the linen closet. The kitchen is equipped with a refrigerator, a stove, a dishwasher, a microwave and a water cool. Plenty of perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed. The Licensee will supplement the non-perishable foods with additional proteins. Medications are stored in a locked kitchen cupboard. The common bathroom is equipped with a walk in shower, a toilet, a sink, a shower chair, grab bars and a toilet riser. No slip resistant mats were observed, Water temperature was tested and read 118.9 degrees Fahrenheit. Hygiene products are stored in the locked bathroom cabinets. The auditory devices on the outside exiting doors were operational. The only fire extinguisher, purchased on 12/10/24 is located by the front door. The hard wired smoke detectors located in the resident bedrooms and the combination smoke/carbon monoxide detector located in the living room and resident hallway were tested and were operational. The first aid kit contained the required scissors, tweezer and thermometer. No first aid manual was observed on today's visit The required postings were observed but the licensee needs to purchase a current labor poster. The laundry room located in the back was observed with a washer and dryer. Also located by the laundry room is a storage shed. A long ramp for wheelchair use to exit from the living room, bedroom #3 and bedroom #2, separates the back property utilized by the ADU. No bodies of water was observed on the property Located in the front is a gazebo furnished with seating and a table for outside activities. Continued on LIC809-C Page 3. The trash cans normally stored in the front yard were observed on the street for trash pickup. Trash cans were in good condition. Per tour of the front yard, along the sides of the home and backyard, the outside areas were clean and well maintained. The Annual Inspection visit was initiated on 11/19/25, but due to laptop issues, a partial report was generated but could not completed for delivery on the date of the site visit. The Report and citations were .completed on 11/20/25 and emailed to the Administrator Designee, Erna Gevorgyan, after telephone contact for her signature. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not cited on today's visit will be cited on a return visit. Exit interview was conducted, Appeals Rights discussed and a copy was provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

Type of visit: Required - 1 Year

PAGE 1 Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 12:40 p.m. Upon arrival, there was two (2) staff and six (6) residents present. Staff called Administrator Designee and they arrived shortly after. The LPA met with Administrator Designee Erna Gevorgyan and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA toured the kitchen/food service area at 1:24 p.m. The hot water was measured at 106.7 degrees Fahrenheit at 1:25 p.m. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of two (2) day perishable and seven (7) day non-perishable food. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a cabinet. There were no pesticides or poisons observed near any food areas. LIVING ROOM/DINING ROOM: The LPA inspected the living room and dining room area. The common areas were observed to be properly furnished and clean at the time of the visit. Furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 5:27 p.m., the hardwired smoke detector(s) and carbon monoxide detectors were tested and operational. Fire extinguishers was observed fully charged and purchased on 01/11/24. The LPA observed required postings throughout the common spaces. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. The last emergency disaster drill took place on 08/21/2024 and are conducted quarterly. Activities were observed in the common areas. An adequate supply of emergency food and water was observed in the front storage cabinets. (Report Continued on LIC 809C...2nd page) 2ND PAGE (Report Continued from LIC 809...) OUTDOORS/ STORAGE: Located at the back of the facility is an alternate dwelling unit (ADU) that was recently added. Permits were obtained on 3/23/22 and the ADU was approved for occupancy on 6/30/23. Copy of Certificate of Occupancy was obtained today. The LPA observed a sufficient supply of Personal Protectant Equipment (PPE) in the storage unit outside. Cleaning supplies and toxins were observed in the locked laundry room inaccessible to residents in care. There is a locked laundry room with a washer and dryer on the premises. The backyard is not used by the residents in care. The front yard area has a sufficient amount of space with shaded area with furniture including a table and chairs for resident use. The LPA observed a clear passageway in case of an emergency. There were no bodies of water noted at the time of the visit. BEDROOMS: There are four (4) total rooms. Three (3) are currently designated as shared resident bedrooms and One (1) as a storage room. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. BATHROOMS: There are three (3) bathrooms one (1) for shared resident use, One (1) for private resident use and one (1) for staff but can be used in an emergency. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water was measured at 108.5 degrees Fahrenheit at 1:36 p.m. for the shared bathroom and 108.0 degrees Fahrenheit at 1:44 p.m. for the private bathroom all within the required range. (Report Continued on LIC 809C... 3RD PAGE) 3RD PAGE (Report Continued from LIC 809C 2nd page) RECORDS: Records review began at 1:55 p.m., six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time. Four (4) Personnel records including both the Administrator and Administrator Designee’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review for six (6) residents began at approximately 4:40 p.m. Medications are centrally stored in a cabinet in the kitchen locked and inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time. The LPA interviewed two (2) staff, and three (3) residents during the inspection. During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, Certificate of Occupancy and current liability insurance. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection visit using the complete CARE Inspection Tool and was let into the home by staff. Erna Gevorgyan, Designated Staff, was contacted via telephone and she arrived at the facility to conduct the visit at 10:52am to conduct the visit. Hovhannes Ispiryan, Administrator is out of town. The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 4 bedrooms, 2 private bathrooms and a common bathroom. The facility is fire cleared for 1 AMBULATORY, 4 NON-AMBULATORY and 1 BEDRIDDEN resident. Located at the back of the facility is a alternate dwelling unit(ADU) that was recently added. Permits were obtained on 3/23/22 and the ADU was approved for occupancy on 6/30/23. Copies of the permits were obtained today and a copy of the Certificate of Occupancy will be provided to the Department as soon as the Licensee receives a copy. The address assigned to the ADU is 6509 Bonner Avenue and is currently occupied by the Licensee and his family. Due to time constraints, the following domains were reviewed on today's visit: Infection Control, Operational Requirements, Staffing, Personnel Records: Training, Resident Records: Incident Reports, Resident Rights: Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, Residents with Special Health Needs. The Physical Plant and Environmental Safety Domain will be completed on a return visit. During today visit, all the following files were reviewed: 6 staff files, 4 resident files, Infection Control Plan, Emergency Disaster Plan and the Plan of Operations. Continued on LIC809-C Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any citations not issued on today's visit will be issued on a return visit. Exit interview was conducted, APPEALS RIGHTS, discussed and a copy was giventhe state’s words, verbatim · CDSS document, Nov 13, 2023