Aaa Jerusalem Stars

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:10AM. LPA met with staff and Administrator Kristina Adamyan upon arrival. Entrance interview conducted. At 11:12AM, the LPA along with staff and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 11:12AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. At 11:13AM, LPA observed the knives stored accessible to residents as the lock on the drawer was inoperable. Administrator stated that the lock will be replaced. LPA observed locked and inaccessible cleaning solutions under the sink. Fire extinguisher by the kitchen area was fully charged and last purchased on 12/01/2025. At 11:18AM, LPA observed a fruit fly infestation in the pantry. Administrator stated they have hired a monthly exterminator service and that there are fruit fly traps by the kitchen sink. LPA advised to install fruit fly traps in the pantry as well. Administrator stated they will call an exterminator to address the fruit flies. BEDROOMS: There are five (5) resident bedrooms; four (4) are designated for single-use and one (1) is designated for shared-use. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 11:27AM, LPA observed the direct exit in Bedroom #3 obstructed with a metal pipe in the sliding door, preventing it from opening. Staff removed the metal pipe immediately. Bedroom #3 has a bedridden fire clearance, and LPA explained that the direct exit cannot be obstructed due to fire clearance and immediate health/safety hazards. Report Continued on LIC809-C. At 11:35AM, LPA observed Bedroom #4 with a heavily stained mattress with no mattress cover, rubber sheeting, or pads. The mattress had one sheet that was lifted in the corners with the mattress exposed. Administrator stated the mattress will be replaced and a waterproof cover will be installed on the mattress. At 11:43AM, LPA observed the vinyl floorboards in Bedroom #4 to be peeling and a potential fall hazard. LPA observed a locked staff room in the hallway. Auditory exit alarms were functional. RESTROOMS: There are four (4) restrooms of which three (3) are designated for resident-use and one (1) is designated for staff and visitor use. At 11:27AM, LPA observed the slip-resistant mat in the hallway bathroom to be in unsanitary and inoperable condition. Administrator stated the mat will be replaced. At 11:41AM, LPA observed the restroom attached to Bedroom #4 to not have appropriately running hot water, the toilet lid removed and on the floor, toilet in unsanitary condition, restroom not stocked with necessary supplies such as toilet paper and a trash bag in the trash can, the trash can with the lid removed and on the toilet, and the sink in unsanitary condition. Staff repaired the hot water which LPA measured from 11:56AM-12:02PM to reach 105.1 degrees F. At 12:31PM, LPA observed the hallway restroom with an unsanitary sink. Hot water temperatures were measured in resident restrooms and were between 105.1-106.5 degrees F, which is within the required range. Restrooms were equipped with functional grab bars. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. At 12:38PM, LPA observed a shed in the backyard containing extra mattresses and beds with a nonfunctional lock. LPA observed the mattresses in disrepair and unsanitary as they were covered in dirt. Administrator stated that the mattresses were meant to be thrown away and are not for resident-use. There is a side gate which was observed to self-latch. At 12:40PM, LPA observed the emergency exit passageway obstructed with trash bins and a ladder. Staff removed the obstructions during the visit. No bodies of water noted. COMMON AREAS: At the time of the visit, living room and family room furniture were observed to be in good condition. There is one (1) fireplace which was observed adequately screened. The facility maintained a comfortable temperature. At 12:41PM, LPA observed the window screens for the sliding exit doors in the family room and Bedroom #4 to be uninstalled and removed from its tracks. Administrator stated they did not know why the screens were removed and stated that they will be reinstalled. At 12:52PM, smoke detectors and carbon monoxide detectors were tested and were operational at the time of the visit. LPA observed required postings throughout the common spaces. Report Continued on LIC809-C. GARAGE: LPA observed a locked garage adjacent to the kitchen that contained a washer and dryer, additional refrigerator/freezer, additional food and supplies, and an office area. INTERVIEWS: During today’s visit, LPA interviewed four (4) residents and three (3) staff. MEDICATION REVIEW: Will be reviewed during annual continuation. RECORD REVIEW: Will be reviewed during annual continuation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Will be reviewed during annual continuation. Due to time constraints, the annual inspection will be finished on a later date. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500 for fire clearance violation. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 22, 2025

The state marks this report as 12 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Staff are unable to communicate effectively Staff mishandled a client while in care Staff did not provide adequate care and supervision to a client

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegations listed above 11:00AM. Upon arrival, LPA met with staff and Administrator Kristina Adamyan who arrived at 11:40AM. Entrance interview conducted. During today's visit, LPA conducted a physical plant tour upon entry, interviewed three (3) of six (6) residents between 11:04AM-11:35AM as two (2) residents were asleep and one (1) resident was away from the facility during the visit, interviewed two (2) staff and the Administrator between 11:36AM-12:10PM, reviewed and obtained copies of pertinent documents relevant to the investigation at approximately 12PM, and discussed allegations with Administrator at 02:27PM. Report Continued on LIC 9099-C. Unsubstantiated It was alleged that staff are unable to communicate effectively due to language barriers. Two (2) out of three (3) residents interviewed stated that there is a language barrier with staff, but that staff understand basic English and use translators on their phone for clarification. Residents expressed no immediate concerns of staff unable to understand or assist residents. Residents stated that staff make the effort to understand and use other means such as hand gestures, online translators, and calling the Administrator for translation whenever necessary. LPA interviewed two (2) of two (2) staff and observed that staff were able to communicate in English and understand LPA. Staff #1 (S1) was able to state the types of abuse and resident personal rights. Staff #2 (S2) was unable to state the types of abuse and personal rights in English, but was knowledgeable in their language after LPA used a translator. Staff stated that there is a language barrier at times, but they use multiple methods to ensure that staff and residents understand one another. LPA reviewed training records and observed medication, dementia care, and annual caregiving training within the past year. Administrator stated that S2 will be getting additional training in English. Based on interviews, observation, and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. 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 above allegation “Staff are unable to communicate effectively” is deemed UNSUBSTANTIATED at this time. It was further alleged that staff mishandled Resident #1 (R1) by dropping them after a wheelchair transfer and leaving them unsupervised. Interviews with residents, staff, and Administrator revealed that on 05/09/2025, R1 was using their new electric wheelchair but had not yet received proper instructions for use as the chair was received on 05/08/2025. R1 was outside with staff supervision and began to slip from the chair. R1 asked S1 and S2 for assistance and staff assisted R1 by lifting R1 up and into a more secure position on the chair. R1 stated they were in pain after the transfer assistance. Staff called the Administrator who called 9-1-1 and the paramedics transferred R1 to the hospital upon request. R1 returned same day with no new orders or changes of condition. R1 stated they do not fault the staff for the incident. R1 had a catheter pump that was located towards their back where staff pulled R1 up from. Paramedics and R1 were concerned that the pump could have moved but after further evaluation at the hospital, it was determined that the pump was intact. R1 and staff stated that R1 was being supervised outside and at no time were they left alone. Report Continued on LIC 9099-C. LPA interviewed two (2) other residents who expressed no concerns of lack of supervision, inadequate care, or mishandling. LPA reviewed the staff roster which indicated adequate staff coverage at all times. During the visit, LPA reminded Administrator of reporting requirements and to submit a written incident report to the Department within seven (7) days of occurrence. Administrator stated they will submit the report. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations “Staff mishandled a client while in care” and “Staff did not provide adequate care and supervision to a client” are deemed UNSUBSTANTIATED at this time. Administrator designated staff Karyna Deputativa to sign the report. No deficiencies cited at this time. Exit interview conducted telephonically with Administrator. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2025 · control 29-AS-20250512123236

Allegation investigated: Staff did not provide resident with proper notification prior to fee increase

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation with the purpose of delivering findings for the allegation listed above at 03:13PM. LPA met with staff. Administrator Kristina Adamyan was unable to arrive for the visit. Reason for the visit was explained. During the initial visit on 12/30/2024, LPA conducted a brief physical plant tour, conducted interviews with two (2) staff members and four (4) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with Administrator Adamyan. It was alleged that Resident #1 (R1) was being evicted from the facility as R1 was unable to pay the $250 rent increase given with one-month notice. Interviews with staff and R1 did not support R1 being evicted. No eviction notice was reported to the Department and evidence of a notice was not observed. Report Continued on LIC 9099-C. Unsubstantiated Interviews with staff and R1 supported that R1’s agreed-upon rate at admission was $1200 on 04/29/2022, but Administrator verbally agreed to a lower rate upon R1’s request. LPA reviewed records and observed the monthly rate in the admission agreement to be $4200, of which $1200 is from SSI and $3000 is from Medi-Cal. Administrator stated that R1 informed them on 12/30/2024, that R1 will be moving to a homeless shelter as they cannot afford rent. Administrator offered to lower R1’s rate to $800 and transfer R1 to a shared room at their other facility, which R1 also confirmed with LPA during interview. R1 further confirmed that their rate was informally lowered upon request and that they were offered a rate as low as $600. While rates were changed without the required notice, the changes were made informally and were decreased so that R1 could make their payments, not increased. R1’s agreed-upon rate in their signed admission agreement is $1200, and Administrator did not increase above this rate without the proper notice required. LPA interviewed three (3) other residents and reviewed records; no evidence of the allegation was observed. LPA held a discussion with the Administrator about regulations surrounding rate changes and informed Administrator to properly document and notify rate increases. Health and Safety Code section 1569.655(a) states “if a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives…”. As rates were not increased from the rate in R1’s admission agreement, a 60-day prior notice is not required in this scenario. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation “Staff did not provide resident with proper notification prior to fee increase” is deemed UNSUBSTANTIATED at this time. Administrator telephonically designated staff Karyna Deputativa to sign the report. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 27, 2025 · control 29-AS-20241230093006

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 09:48AM. LPA was greeted at the door by staff and the reason for the visit was explained. Administrator Kristina Adamyan arrived at 10AM. Entrance interview conducted. At 09:49AM, the LPA along with staff and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN/GARAGE: The LPA inspected the kitchen/food service area at 09:49AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Knives were stored locked and inaccessible in a kitchen drawer and cleaning solutions were stored in a locked cabinet under the sink. Fire extinguisher by the kitchen area was fully charged and last purchased on 12/27/2024. LPA observed a locked garage adjacent to the kitchen that contained a washer and dryer, additional refrigerator/freezer, and additional food and supplies. BEDROOMS: There are five (5) resident bedrooms of which four (4) are designated for single-use and one (1) is designated for shared-use. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed a locked staff room in the hallway. All direct exits were clear, and no obstructions were noted. RESTROOMS: There are four (4) restrooms of which three (3) are designated for resident-use and one (1) is designated for staff and visitor use. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The restrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Hot water temperatures were measured in resident bathrooms and were above 120 degrees F. Staff lowered water temperature and was measured within the required range. Report Continued on LIC 809-C COMMON AREAS: At the time of the visit, living room and family room furniture were observed to be in good condition. There is one (1) fireplace which was observed adequately screened. The facility maintained a comfortable temperature of 73 degrees F. At 10:15AM, smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. Auditory exit alarms were functioning at the time of the visit. LPA observed required postings throughout the common spaces. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate which was observed to self-latch and self-close. No bodies of water noted. MEDICATION REVIEW: At 10:20AM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a closet in the entry hallway. All medications including PRNs were labeled, stored, and locked inaccessible to residents. LPA observed six (6) medication errors for discrepancies between logged start dates and pill counts. LPA observed medications not stored in their originally received containers as medications were prepared for a week in advance in pill boxes. LPA observed an evening medication for Resident #1 (R1) being administered in the morning. Administrator stated they will conduct medication trainings with all staff and not prepare medications for more than one (1) day in advance. RECORD REVIEW: Beginning at 11:04AM, LPA reviewed four (4) out of four (4) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are not conducted quarterly. INTERVIEWS: During today’s visit, LPA interviewed three (3) residents and three (3) staff. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 27, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 10:20AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 09/10/2024. Upon arrival, the LPA met with staff. Administrator Kristina Adamyan arrived at 10:35AM and the reason for the visit was explained. Entrance interview conducted. On 09/11/2024, the Department received an incident report stating that on the early hours of 09/10/2024, Resident 1 (R1) left the facility unassisted, and staff were unaware. Resident 2 (R2) was woken up by the light coming from R1’s room and when R2 went to investigate, R2 found that R1 was not in their room. R2 notified Staff 1 (S1) around 12:30AM who went to investigate and found that the main entrance door was open. S1 looked inside and outside the facility and was unable to find R1. S1 notified Administrator Adamyan who arrived at the facility around 12:45AM and looked all throughout the facility and neighborhood. Around 2AM, Administrator Adamyan contacted nearby hospitals and the LAPD who arrived at the facility. During this time, Administrator Adamyan contacted R1’s family who arrived at the facility to continue the search. According to the report, R1 was found around 03:45AM and paramedics were promptly called to assess R1’s vitals. R1 was found to be dehydrated and was transferred to the hospital to receive fluids. R1 was discharged from the hospital around 11AM to the facility. During today’s visit, LPA Barutyan conducted a brief physical plant tour at 10:22AM to ensure there are no health and safety hazards, conducted interviews with the Administrator, two (2) staff members, one (1) resident, and one (1) family member between 10:35AM-12:00PM, and conducted a file review. LPA requested and obtained copies of pertinent documents relevant to the investigation via email on 09/11/2024. Report Continued on LIC 809-C Record review of R1’s physician’s report dated 03/01/2023 indicates that R1 has dementia and is unable to leave the facility unassisted. R1 does not have an updated physician’s report for the current year. Record review of R1's appraisal of needs and services dated 03/15/2022 revealed that R1 requires assistance and guidance in their care plan. R1 does not have an updated reappraisal of needs and services. Interviews conducted with staff revealed that R1 is not able to ambulate and staff believe R1 was unlikely to have left the facility without some kind of assistance. LPA was informed that S1 found R1 three (3) hours after the search began in the backseat of R2’s vehicle. Staff stated that S1 did not hear the resident leave because R2 turned off the exit alarm and S1 was in the garage doing laundry. Interview conducted with the Administrator revealed that S1 put residents to bed at 09:30PM. R1 woke up at 11:15PM and was hungry. R2 was also awake and together they went to the kitchen and asked S1 for food. After eating, S1 put R1 to bed and within forty (40) minutes at 12:30AM, R2 notified S1 that R1 was missing and left the facility. S1 found that the front door was open and began the search while also contacting the Administrator. Administrator stated that R2 has a tendency to turn off the exit alarm and S1 does rounds every two (2) hours to check on the residents, which is why R1 was able to leave without notice because S1 had just done a round forty (40) minutes prior. Administrator contacted the family, the LAPD, and nearby hospitals around 2AM. Administrator stated that R1 was eventually found by S1 at 03:30AM in the backseat of R2’s car of which the door was left ajar. According to staff and Administrator, R1 was missing from 12:30AM-03:30AM. Administrator stated that R1 was unlikely to have left on their own because R1’s cane was left behind in their room and R1 is unable to ambulate more than ten (10) feet without it. The driveway was also poorly lit and R1 needs assistance to sit down. Administrator stated it is unclear how R1 could have sat in the car on their own. During the visit, LPA interviewed R1 who was confused and unable to recall any incidents besides going to the hospital last week for an unknown reason. Furthermore, during an interview with R1’s family member, family member stated that the Administrator contacted them at 03:30AM, three (3) hours after R1 was found to be missing. Family arrived at 4AM and R1 was found at 04:30AM, meaning that R1 was missing for a total of four (4) hours. The interview also revealed that family was informed S1 was asleep when R2 notified that R1 was missing. Report Continued on LIC 809-C During the physical plant tour at 10:23AM, LPA observed the auditory exit alarm to R1’s room was turned off. Staff turned on the alarm during the visit and was functional and operating. During LPA’s interview with R1’s family, it was revealed that they have never heard the auditory exit alarm or observed the light on the device to be on. According to the family, they were not aware that one was installed as the device has been kept off and were only informed that there was a device when the LPA asked staff to turn on the alarm while family was visiting. Staff interviews revealed that the auditory device had just recently been turned off earlier in the day because the sliding exit door was opened to let a breeze in. Staff and Administrator were informed that the devices need to be on at all times. At 10:25AM, LPA observed the auditory exit alarm in the family room was turned off. Staff turned on the alarm during the visit and was functional and operating. At 10:26AM, LPA observed the living room to be missing an auditory exit alarm. Upon further inspection, LPA observed an uninstalled auditory exit device on the piano in the living room at 10:30AM. Administrator was unable to remain at the facility for the delivery report. LPA delivered report to caregiver Ana Gutierrez who signed in the Administrator's place. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Sep 18, 2024

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section as R1 was able to leave the facility unassisted which posed an immediate risk to residents' safety.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Administrator agreed to conduct an in-service training with staff to review section cited. In addition Licensee agreed to submit a letter of understanding to LPA via email by 09/18/2024 EOD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Sep 24, 2024

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be... ensuring the following:(5)Each resident with dementia shall have an annual medical assessment...and a reappraisal... This requirement is not met as evidenced by: Based on record review, the facility did not comply with the section cited above as R1 has dementia and does not have an updated medical assessment and reappraisal which poses a potential health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Administrator agreed to obtain an updated medical assessment and perform a reappraisal of resident's needs and services. Administrator agreed to submit proof to CCL by 09/24/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(j) · Plan of correction due date: Sep 24, 2024

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that two (2) auditory exit alarms were observed off and one (1) exit door did not have an auditory device installed which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Administrator will ensure that auditory devices remain on at all times. Administrator agreed to install an auditory device to the sliding exit door in the living room and will submit proof to CCL by 09/24/2024.

Allegation investigated: Staff are not ensuring a safe environment for resident in care.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 1:33 p.m., the LPA met with staff and explained the reason for the visit. At 1:50 p.m., the Licensee, Kristina Adamyan arrived at the facility. Between 1:51 p.m. and 2:23 p.m., the LPA conducted interviews with the Licensee, one (1) staff and five (5) residents. At 1:55 p.m., the LPA obtained copies of pertinent documents. At 1:57 p.m., the LPA along with the Licensee conducted a physical plant tour. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Staff are not ensuring a safe environment for resident in care. It was alleged that Resident #1 (R1) felt unsafe due to feeling a hand on their neck while sleeping but when R1 turned on the lights in the room, R1 did not see a person in their room. During the time of the visit, the LPA conducted interviews with five (5) residents, including R1. The interviews revealed that the residents feel safe at the facility and feel well taken care of. No safety concerns were brought up during the resident interviews. Staff interview revealed that staff ensure that front and back doors remain locked. Staff stated that they check on residents every two (2) hours during the night to ensure the wellbeing of the residents. Licensee interview revealed that the facility has cameras in the common areas, and throughout the exterior perimeter of the facility for safety reasons. The Licensee stated that herself and her staff are always checking on the health and safety of all the residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 16, 2024 · control 29-AS-20240509112359

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. Licensee Kristina Adamyan arrived shortly thereafter. The LPA and the licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Kitchen: Knives are stored in a locked drawer in the kitchen. The facility has a sufficient supply of perishable and nonperishable food. Additional food is located in the garage. There is an adequate supply of emergency food and water. Appliances were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet in the kitchen and in the garage. At 1:27 p.m. the LPA and the licensee observed five cockroaches in a cupboard under the oven. Bedrooms: The facility has six bedrooms. Five rooms are designated for resident use. There are four private resident bedrooms (Rooms #1, 2, 4, 5) and one shared room (Room #3). Room #3, Room #4, and Room #5 have direct exits to the outside. Rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. Room #6 is a designated staff room. At 12:30 p.m. the LPA and the licensee observed the staff's bedroom to be unlocked. Over the counter medication (Nexium) with one pill on top of the lid, was observed within reach of the residents. The Licensee promptly removed the medication and locked the room. Bathrooms: There are four bathrooms, and out of the four bathrooms, one is designated as a staff bathroom. Restrooms are clean and sanitary with grab bars and non-skid surfaces. Rooms #3 and #5 have an attached bathroom. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms. At 12:40 p.m. the LPA and the licensee observed shaving razors on top of the sink and under the sink, to be within reach of residents. The non-skid mat in the bathroom #1 was found to have mold. Common Areas: The common areas are appropriately furnished, and the lighting is adequate. Resident and staff records are stored in the garage. There is not a fireplace in the living room. Medications are stored in a locked closet near the entrance. Fire extinguishers were purchased on 11/26/2023. Smoke detectors and common monoxide detectors were tested and were operational at the time of the visit. There is a functioning telephone on the premises. Emergency exit plans are posted throughout the facility. Other required postings are near the front entrance. Outdoor Area: The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. There is a door w/gate with a self-latching mechanism for persons to enter the front yard. There is a locked storage shed in the back yard. There are no bodies of water on the premises at the present time. The garage is accessible from the house; the door was unlocked at the time of the visit at approximately 1:15p.m. The washer and dryer are in the garage, along with the cleaning supplies. RECORDS: Records review began at 2:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files were missing the annual required hours of training for staff. MEDICATIONS: Medications review began at 4:23 p.m.; medications are centrally stored and locked in a cabinet in a closet; medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. The following errors were observed during the medication review. Medication for one resident was discontinued by physician, but no note was found in the resident’s record. Additionally, three new medications were prescribed, and doctor’s new order was missing from resident’s record as well the new medications were not listed in the Centrally Stored and Destruction Record. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LICs 9099-D). The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster Deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 28, 2023