Aaa Royal Senior Living Facility

Allegation investigated: Staff interfered with resident’s visit. Staff confined resident to their room. Staff did not provide resident or their authorized representative with requested information in a timely manner. Staff intimidated resident into signing paperwork.

This is an amendment to the original report issued on 12/16/2025, to make correction to the final findings of the above allegations. At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit. LPA met with the staff and the Administrator Kristina Admayan was contacted via phone. The Administrator arrived shortly after and LPA explained the reason for the visit. An initial complaint visit was conducted on 02/04/2025. LPA obtained resident and staff roster and other pertinent information which include, but not limited to Physician's Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. LPA conducted and physical plant tour of the facility. Interviews were conducted with the Administrator, a Placement Agent, one (1) Staff, three (3) out of four (4) residents who were available at the facility. During today's visit, LPA conducted an interview with one (1) out of six (6) residents who was available. Continue on LIC 9099C Substantiated Allegation: Staff did not adequately assist resident with care needs in a timely manner. It was alleged that Resident #1 (R1), who uses a walker and requires assistance with ambulation and restroom use, experienced delays in staff response times when requesting assistance. It was further alleged that due to delayed responses, R1 attempted to ambulate independently and nearly fainted in the restroom on an unknown date. To investigate this allegation, LPA conducted interviews with the Administrator and Staff #1 (S1). Both denied the allegation. The Administrator stated that R1 always received assistance shortly after requesting help and that staffing levels were sufficient to meet resident needs. Staff reported that residents are monitored and assisted as needed. LPA interviewed R1 on 02/04/2025, who reported concerns regarding delays in staff responding to requests for assistance and described an incident on an unknown date in which R1 nearly fainted while using the restroom. During the visit on 02/04/2025, LPA observed staff present and providing care and supervision to all residents including R1. Based on LPA’s observation during the initial and subsequent visits, staff were available to assist residents and respond to care needs. Based on interviews conducted and LPA’s observation during the visit, there was insufficient evidence to support the claim that staff did not adequately assist R1 with care needs in a timely manner. Therefore, the allegation is Unsubstantiated. The finding is based on information gathered during the investigation regarding conditions and practices during the time R1 resided at the facility. At the time the investigation concluded, R1 was no longer residing at the facility. Allegation: Staff did not respect resident’s choices regarding their care needs. It was alleged that staff did not respect R1’s expressed care preferences. Specifically, it was alleged that an unknown individual provided a shower to R1 without proper identification and performed an unsolicited massage despite R1 verbally objecting. To investigate this allegation, LPA interviewed the Administrator and S1, both of whom denied the allegation. The Administrator stated that showers are provided by a designated shower aide and that the facility does not provide massages to residents. Although the Administrator was initially unable to identify the individual who provided the shower at the time of questioning, documentation obtained during the course of the investigation clarified that R1 was enrolled in hospice services with Glendale Hospice Inc beginning 01/24/2025. Records reviewed indicate that R1 received two hospice visits dated 01/28/2025 and 01/31/2025. During both visits, hospice staff provided shower assistance using a shower chair and applied lotion to R1’s skin as part of routine personal care. Documentation further reflects that R1 was discharged from hospice services on 01/31/2025 at the request of R1’s Power of Attorney (POA), who revoked hospice benefits and service Continue on LIC 9099C Based on documentation reviewed and interviews conducted, the personal care services in question were provided by hospice agency staff, a third-party provider, and not by facility staff. While R1 expressed dissatisfaction with the services received, there is insufficient evidence to support that facility staff failed to respect R1’s care preferences. Therefore, the allegation is Unsubstantiated. Allegation: Staff did not provide the resident with adequate food service. It was alleged that staff failed to provide Resident 1 (R1) with adequate and appropriate meals, including meals consistent with R1’s dietary needs. Additionally, it was reported that R1 was repeatedly served cold sandwiches and inappropriate meals. To investigate this allegation, the Licensing Program Analyst (LPA) interviewed the Administrator, who denied the claim and stated that meals are freshly prepared. The Administrator further indicated that R1 was provided with a special low-sodium diet in accordance with their dietary requirements. Facility staff also denied the allegation, reporting that residents, including R1, are served a variety of meals, including hot meals, and are offered substitutions when necessary. On 02/04/2025, the LPA interviewed R1, who expressed dissatisfaction with the meals and stated that cold sandwiches were served on several occasions. R1 also reported that staff encouraged them to eat the meals provided when alternatives were refused. During the initial visit on 02/04/2025, LPA observed lunch service. Residents were served a toasted sandwich, a bowl of soup, salad, juice, and water. Additionally, interviews with two (2) other residents revealed no concerns regarding food service. Based on the LPA’s observations and interviews conducted, residents were observed to be receiving adequate meals consistent with their dietary needs. Therefore, there is insufficient evidence to support the allegation that staff failed to provide R1 with adequate food service or meals consistent with dietary requirements. Therefore, the allegation is deemed Unsubstantiated at this time. This finding is based on information gathered during the investigation regarding conditions and practices while R1 resided at the facility. At the time the investigation was concluded, R1 was no longer residing at the facility. Continue on LIC 9099C Allegation: Staff spoke to resident in an inappropriate manner. It was alleged that staff spoke to R1 in an inappropriate and disrespectful manner, including yelling and making demeaning statements. To investigate this allegation, LPA interviewed the Administrator and S1, both of whom denied speaking inappropriately to R1 and stated residents are treated respectfully. During initial visit on 02/04/2025, LPA interviewed R1, who reported being yelled at when requesting assistance and when asking questions regarding showers and meals. R1 reported being told, “Eat it or starve.” During the initial visit, LPA did not observe any staff speaking inappropriately to R1 or any other residents in care. Moreover, LPA observed that all residents are treated with respect and dignity. Additionally, on 02/04/2025, LPA conducted interview with three (3) out of four (4) residents of which two (2) residents did not express any concern regarding the allegation and informed LPA that they are being spoken to appropriately. Therefore, based on interviews and observation this allegation is Unsubstantiated at this time. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Appeal rights explained. Exit interview conducted and copy of this report signed and provided. Allegation: Staff interfered with resident’s visit. It was alleged that staff interfered with R1’s authorized healthcare visits. Specifically, it was alleged that a Home Health Nurse sent by R1’s physician and authorized by R1’s Power of Attorney (POA) was prevented from assessing R1. To investigate this allegation, LPA interviewed the Administrator, who denied interfering with visits and stated R1 was already receiving hospice services at the time. Additionally, LPA interviewed the Home Health Nurse, who stated that on 01/31/2025 she was prevented from completing an assessment by a hospice nurse who stated R1 was already enrolled in hospice services and that hospice was responsible for care. The nurse left the facility without completing the assessment. LPA confirmed through interviews that hospice enrollment occurred without documented POA consent. Based on the interviews and corroborating information, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Allegation: Staff confined resident to their room. It was alleged that staff confined R1 to their room and restricted their access to common areas, allowing them to leave only for meals. To investigate this allegation, LPA interviewed the Administrator, who denied restricting residents and stated residents may use common areas freely. Staff reported that residents are allowed in the living room and participate in activities. During initial visit on 02/04/2025, LPA interviewed R1, who reported being told they had to remain in their room and could only come out for meals. During the initial visit on 02/04/2025, LPA observed residents spending the majority of the day in their rooms, no activities being offered, and residents being directed back to their rooms immediately after meals. Based on interviews and observation, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Continue on LIC 9099C Allegation: Staff did not provide resident or their authorized representative with requested information in a timely manner. It was alleged that staff failed to provide R1 and their authorized representative (POA) with requested information regarding care providers and medical decisions. To investigate this allegation, LPA interviewed the Administrator, who stated attempts were made to contact the POA regarding hospice enrollment. LPA reviewed the Administrator’s outgoing call logs and did not observe any calls placed to the POA. Furthermore, LPA interviewed the POA and placement representatives, who stated they were not informed of hospice enrollment and were not provided with information regarding individuals brought into the facility to care for R1. Based on interviews and record review, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Allegation: Staff intimidated resident into signing paperwork. It was alleged that staff intimidated R1 into signing paperwork by using threats or coercive behavior. To investigate this allegation, LPA interviewed the Administrator, who denied forcing or intimidating R1 and stated paperwork was explained prior to signing. Facility staff denied witnessing coercion. During the initial visit on 02/04/2025, LPA interviewed R1, who reported that the Administrator and an unknown male pressured them to sign paperwork, stating they had to sign “or else.” R1 reported the male became angry and that they feared physical harm. LPA observed R1 display fear and emotional distress while recounting the incident. The facility was unable to provide documentation demonstrating informed consent or POA involvement. Based on interviews and observation, the allegation is Substantiated. The finding is based on conditions and practices observed during the period R1 resided at the facility. At the time of the investigation conclusion, R1 was no longer residing at the facility. Deficiencies issued and appeal rights explained. Exit interview conducted and copy of this report signed and provided.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 31-AS-20250131102508

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Apr 14, 2026

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building or on facility premises by day or night. This requirement is not met as evidenced by: Based on interviews and LPA's observation the Licensee did not comply by restricting R1’s movement by directing R1 to remain in his/her room except for meals. LPA observed residents spending most of the day in their rooms and being directed back after meals.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Administrator will ensure residents may freely access common areas and will retrain staff on personal rights. The POC was previously cleared on 12/19/2025 for the original report dated 12/16/25, POC is cleared during today's visit. This poses a potential personal rights risk.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Apr 14, 2026

87468.2 Additional Personal Rights... (a) …residents… shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications,....This requirement is not met as evidenced by: Based on interviews and record review the Licensee did not comply by interfered with R1’s authorized healthcare visit when a Home Health Nurse was prevented from completing an assessment. This poses a potential personal rights risk.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Administrator will ensure residents and POAs may receive authorized outside healthcare services. Staff will be retrained on visitor and medical access rights. The POC was previously cleared on 12/19/2025 for the original report dated 12/16/25, POC is cleared during today's visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Apr 22, 2026

Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee....., including ongoing evaluations, as appropriate to their needs.This requirement is not met as evidenced by: Based on interviews and record review, the Licensee did not comply with the above section by failing to provide R1 and his/her authorized representative with requested information regarding care and services in a timely manner. This poses a potential personal rights risk.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Administrator will ensure that residents’ authorized representatives are informed of care and service updates in a timely manner. Staff will be trained on communication requirements and a communication log will be maintained to document all notifications. Administrator will monitor compliance.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 22, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse,,,,,,,This requirement is not met as evidenced by: Based on interviews and record review, the Licensee did not comply with above section by subjecting R1 to intimidation and coercive behavior during the signing of paperwork. This poses a potential personal rights risk.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Administrator will ensure residents are not subjected to intimidation or coercion when signing any paperwork. All documents will be explained prior to signature, and staff will receive training on residents’ personal rights. Proof to be submitted to LPA by POC due date.

Type of visit: Office

Licensing Program Manager (LPM) Nichelle Gillyard and Licensing Program Analyst (LPA) Huma Rahimi met with Kristina Admayan to conduct an Informal Conference held at the Woodland Hills South Adult and Senior Care Regional Office. The purpose of the informal was to discuss recent deficiencies. AAA Royal Senior Living Facility was first licensed 05-12-2023 and since being licensed the licensee has been cited for many deficiencies that are of concern and need to be addressed. Case Management Visit (CM) -9-23-2023-Reporting Requirements, Injections Complaint -31-AS-20250915193556-Substantiated. Staff mismanaged resident's medication. Resident did not receive medications as prescribed. Deficiency: Incidental medical and dental. CM – 02-04-2025- Deficiencies: Incidental Medical and Dental-meds not given as prescribed. Reporting Requirements failure to report incident of refused medications. CM-12-09-2024-Deficiencies: Reappraisal-No reappraisal for change in medical condition. CM- 09-17-2024-Deficiencies: Criminal Record Clearance- Staff not fingerprint cleared. Civil penalty issued. Complaint-31-AS-20231214153230- Substantiated. Staff did not provide adequate ALWP accommodation to resident in care. Deficiency: Personal Rights of Residents in all Facilities. Complaint-31-AS-20231108143829-Substantiated. Staff are not ensuring the resident is taking medication as prescribed. Deficiency: Incidental Medical and Dental Care. Continue on LIC 809C After reviewing the deficiencies above, LPM discussed the Technical Support Program (TSP) with the Administrator. During the office visit the Administrator acknowledged to receive TSP assistance to bring the facility in compliance. Other: LPM discussed and provided copies of title 22 regulations to the Administrator related to diabetes, restricted health conditions, general requirements for allowable health conditions, injections, incidental medical and dental care. Exit interview conducted. Copy of report signed and provided.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Case Management - Deficiencies

At 12:25 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20250915193556. LPA met with Staff #2 (S2) Karyna Deputativa who granted access to facility. The Administrator was contacted and the Administrator arrived shortly after. LPA explained the reason for the visit. During the initial complaint visit that was conducted on 09/22/2025, LPA was informed that Resident #1 (R1) was hospitalized on 09/10/2025 due to dizziness, not taking insulin for three (3) days associated with sweating, and polydipsia. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA informed the Administrator to submit an incident report that occurred on: 09/10/2025 (one incident) Continue on LIC 809C During the course of the complaint investigation LPA's review of R1's physician's report revealed that R1 cannot manage their own medications and injections. R1 diagnoses requires injections (insulin) to manage his/her diabetes. According to the Administrator and staff #1 (S1) interviewed, injections were given to R1 by S1 who is not an appropriate skilled professional. Additionally, LPA was informed that R1 is not receiving any HomeHealth nor hospice services. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Sep 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Sep 24, 2025

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 09/10/25, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report was submitted to RO on 09/22/25 and POC cleared during today's visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(b)(1) · Plan of correction due date: Sep 24, 2025

(b) In addition to Section 87611...retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by: Based on record review and interview, licensee failed to ensure R1 who is unable to administer injections by self, per physician's report and had injections administered by someone other than an appropriately skilled professional, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Administrator will submit a written plan on how this deficiency will be corrected by POC due date 09/24/2025. The Administrator also agreed to provide HomeHealth Services/Nurse to R1 to Administrator Insulin to R1 by the POC due date.

Allegation investigated: Staff mismanaged resident's medication. Resident did not receive medications as prescribed.

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit. LPA met with the Staff Shushanik Mkrtchyan and the Administrator Kristina Admayan was contacted via telephone. LPA explained the reason for the visit. The Administrator arrived at the facility at 9:45 AM. During course of the investigation, interviews and record review were made. At 9:50 AM, LPA requested resident and staff roster. At 9:55 AM, LPA conducted and physical plant tour of the facility. At 10:00 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Centrally Stored Medication Record (CSMR), Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. Between 10:15 AM to 12:25 PM, LPA conducted an interview with the Administrator, Staff #1 (S1), and four (4) out of four (4) residents. Continue on LIC 9099C Substantiated Staff mismanaged resident's medication. It was alleged that the facility did give Resident #1 (R1) insulin for three (3) days. To investigate this allegation LPA conducted an interview with the Administrator who denied the allegation and informed LPA that they always provide medication to all the residents in a timely manner without any discrepancy. However, review of R1's Centrally Stored Medication Record (CSMR) revealed that eleven (11) out of eleven (11) prescribed medications have discrepancies and were not provided as prescribed. Furthermore, review of R1's hospital records revealed that R1 was hospitalized from 09/11/2025 through 09/13/2025 due to dizziness for not taking his/her insulin for three (3) days. Additionally, the medical records also revealed that R1 experienced sweating, thirstiness, and polydipsia. LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. Therefore, based on the medication record review, medical records, and interviews this allegation is Substantiated. Resident did not receive medications as prescribed. It was alleged that the facility did not have R1's medication at the facility. To investigate this allegation LPA conducted an interview with the Administrator and S1 and both parties interviewed confirmed that R1 currently does not have eight (8) out of eleven (11) prescribed medications due to R1's medical insurance issue. Furthermore, LPA was informed that three (3) out of eleven prescribed medication were also out as of 09/10/2025; however, upon R1's hospitalization R1 was provided three prescribed medication (Divalproex, Lisinopril, and Insuline Aspart) at the hospital. Additionally, LPA reviewed R1's CSMR, and the above information was confirmed that R1's medication run out and the Administrator was unable to refill. Based on interviews and R1's medication review, this allegation is Substantiated. Deficiencies issued and appeal rights explained. Exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 31-AS-20250915193556

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 24, 2025

87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on medication and hospital record reviews and interviews, licensee did not comply with the section above by not assuring that R1's prescribed medications were delivered timely and administered to R1 as prescribed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: Administrator will order the missing medications from the pharmacy and notify doctor regarding the incident. Administrator agreed to schedule vendorized training for all staff by 09/24/25. submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Additionally, Administrator agreed to enroll R1 to HomeHealth services to provide proper insulin intake and injuections.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lorena Casillas conducted the unannounced annual inspection. LPA met with Licensee/Administrator, Kristina Adamyan and explained the purpose of the visit. The facility is licensed for 6 non-ambulatory residents, of which 1 may be bedridden. Bedroom #3 is approved for bedridden. Facility has a hospice waiver approved for 5 residents. LPA conducted a facility tour at 11:30 am with the Administrator and the following was observed: Currently there are three (3) residents in the facility two (2) of which were present and one (1) was out in the community. Infection Control: LPA reviewed facility infection control plan to make sure licensee was following current infection control recommendations. Infection control plan last updated on 05/01/2024. Kitchen: LPA conducted a tour of the kitchen at 11:30 am and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. Medication and knives are stored in locked cabinets. First aid kit furnished and fully equipped. Common Areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 71°F. LPA observed staff and client files locked in the filing cabinet. The smoke detectors and carbon monoxide detectors were tested and observed to be operational. There is one (1) fire extinguishers located in the kitchen hallway. The fire extinguishers was observed to be full however it was last serviced on 03/15/2023. Administrator purchased and had a new fire extinguisher delivered during visit. Continued on LIC809-C Bedrooms: The facility consists of four (4) resident rooms and one (1) staff room. LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client. LPA observed sufficient linens and towels in the hallway closet. All windows had adequate screens, and egress was functioning in all the rooms. Bathrooms: The facility consists of two (2) bathrooms. LPA observed bathrooms to have the appropriated wash your hands signs posted. The bathrooms were clean, with soap and paper towels for residents. Hot water was tested and measured within regulation at 108.6˚ F. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. There is a covered patio and sufficient furniture for all residents. Garage entrance was locked and secure. Garage contains PPE equipment, an additional refrigerator and is used for storage. The laundry area is outside, and detergents are locked in a cabinet located outside as well. There is no swimming pool or bodies of water on the premises. Administrative: LPA collected LIC500, Liability insurance, Administrator certificate and resident roster. Annual fees are current. Staff and Resident Interviews: LPA interviewed residents at 12:00 pm. LPA interviewed staff at 12:30 pm. Resident Files: LPA conducted a file review of staff records at 01:00 pm. Staff Files: LPA conducted a file review of resident records at 01:30 pm. Medications: At 02:05 pm LPA and Administrator reviewed medication and medication records for proper documentation. No deficiencies were observed, an exit interview was conducted, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control # 31-AS-20250131102508. LPA met with the Administrator Kristina Admayan who granted access to facility. LPA explained the reason for the visit. During the visit LPA requested to review the medication for Resident #2 (R2) who seemed drowsy. Review of medication revealed that a bubble pack of thirty (30) tablets of Januvia 25MG (Type 2 Diabetes) which was filled on 12/30/2024 was supposed to be given to R2 one tablet daily. However, LPA observed that there are eight (8) extra tablets in the bubble pack. Additionally, LPA observed a full bubble pack of the same medication which was filled on 01/27/2025. LPA asked the Administrator and the staff for explaining and both stated that R2 refuses taking medication. LPA was informed that R2's POA advised the Administrator not to provide medication if R2 refuses. Administrator informed LPA that they did not inform R2's Physician nor submitted an incident report to Community Care Licensing Department (CCLD). Deficiencies cited. Appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Feb 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 6, 2025

87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. Based on (observation) (interview) (record review)], the licensee did not comply with the section cited above in not assuring that R2's prescribed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Administrator agreed to schedule vendorized training for all staff by 02/06/2025 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B,&D · Plan of correction due date: Feb 11, 2025

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above in not submitting an incident for R2's medication refusal which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Administrator agreed to submit a Special Incident Report (SIR) for R2's medication refusal. Administrator will have to submit a statement of understanding about the above section and reporting requirements.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 31-AS-20240913135055). Upon arrival, LPA met with administrator Kristina Admayan. The purpose of this visit is to issue citation for a deficiency observed during the complaint investigation. On 09/17/2024, LPA Rahimi conducted an initial 10-day visit, at which time copies of pertinent documents from Resident #1 (R1) facility file were obtained and reviewed. Review of documents and interview with the Administrator confirmed that although on 09/06/24, the facility staff observed changes in R1's condition, Administrator failed to do proper reassessment/reappraisal for R1's changes. Pursuant to Title 22, California Code of Regulations, a deficiency will be cited (refer to LIC 9099-D Exit interview conducted, appeal rights discussed, and a copy of this report has been signed and delivered.the state’s words, verbatim · CDSS document, Dec 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Dec 16, 2024

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: Based on record review and interview during investigation, the licensee did not comply with the section cited above by not completing a resident appraisal due to changes in R1’s medical condition, which poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463. Proof of training should be submitted to CCLD by POC date.

Allegation investigated: Staff do not ensure care needs for resident are being met.

At 11:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with Vanissa Campbell, Staff #1 (S1), who granted access to the facility. The Administrator, Kristina Admayan, arrived shortly after and LPA explained the reason for the visit. During course of the investigation, interviews and record review were made. At 11:50 AM, LPA requested resident and staff roster. At 11:55 AM, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician Report, Appraisal Needs and Services Plan, and etc., relevant to the investigation. At approximately 12:00 PM, LPA conducted a physical plant tour. Between 12:10 PM – 1:00 PM, LPA conducted an interview with the Administrator, one (1) staff and four (4) out of five (5) residents who were able to communicate. Continue on LIC9099-C Unsubstantiated Staff do not ensure care needs for resident are being met: In regards to the allegation, it was reported that the staff did not provide any care to Resident #1 (R1) and R1 was neglected. To investigation this allegation, LPA conducted interviews with the Administrator and one (1) staff, and both denied the allegation. LPA was informed that on 09/06/2024, the staff observed that R1’s feet were swollen and immediately notified the Administrator and the physician. Moreover, the physician visited R1 at the facility and ordered laboratory work for R1. Interview with the Administrator revealed that R1’s condition drastically changed on 09/09/2024, and the Administrator called 911. Upon the arrival of Paramedics, it was recommended that R1 needs to be hospitalized; however, R1 refused 911 services. On 09/10/2024, due to R1’s condition being worsened the Administrator called 911 again and R1 was taken to the hospital. Furthermore, LPA conducted an interview with the Physician who confirmed the statement provided by the Administrator and a staff. Interviews with four (4) out of five (5) residents who were able to communicate also expressed no concerns regarding the above allegation. Based on the information obtained, there was insufficient evidence to prove that staff are not providing any care to ensuring that residents' care needs are being met. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 31-AS-20240913135055

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240913135055. LPA met with Staff #1 (S1) who granted access to facility. The Administrator Kristina Admayan was contacted and arrived at the facility shortly after. LPA explained the reason for the visit. LPA was informed that Staff #2 (S2) have been working at this facility for two (2) days. However, LPA reviewed LIS and Guardian and did not observe S2 being fingerprint cleared or associated with the facility. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Sep 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 19, 2024

Criminal record clearance: (e) All individuals subject to a criminal record review... (1) Obtain a California clearance or a criminal record exemption as required by the Department. Based on interview and record review, the licensee did not comply with the section cited above by hiring one (1) staff member on 09/15/2024 without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Administrator agreed to complete S2's fingerprints and associate the staff to the facility. Copy of proof will be submitted to LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection. LPA met with Staff, Vanisa Campbell, and explained the purpose of the visit. Licensee/Administrator, Kristina Adamyan, arrived shortly after to assist with the visit. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. Bedroom #3 is approved for bedridden. Facility has a hospice waiver approved for 5 residents. LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: The facility has an Infection Control Plan posted. Staff are continuing to clean and disinfect the home daily. They are wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time. Physical Plant & Environment Safety: The facility consists of 4 resident rooms, 2 bathrooms, staff office area, living room, dining room, kitchen, and detached garage. The backyard has a shaded area for resident use. There are no swimming pool or bodies of water on the premises. The facility has a carbon monoxide detector located in the hallway near the kitchen. There are no items obstruction the hallways or ramps. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Staffing: All staff members have current CPR & First Aid certificates. Per the licensee, there is sufficient staffing and has backup staffing if needed. Personnel Records-Training: LPA reviewed 3 personnel files. The administrator's (Kristina Adamyan) certificate expires on 12/28/26. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, employee rights form, and in-service training. Staff also have sufficient number of training hours for dementia care. Resident Records-Incident Reports: LPA reviewed 6 resident files that are maintained at the facility. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, preappraisal form, and personal rights form. Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Planned Activities: Facility has sufficient space to provide indoor and outdoor activities to accommodate residents who are physically handicapped. Incidental Medical and Dental: LPA reviewed 6 resident medications and there were no discrepancies observed. Resident using insulin injections can self administer the medication. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency procedures are indicated on the form. Residents with Special Health Needs: Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are currently 2 residents receiving hospice services. There are no residents with prohibited health conditions. There are no deficiencies observed today. An exit interview was held. A copy of this report along with appeal rights are given to the licensee.the state’s words, verbatim · CDSS document, May 18, 2024

Allegation investigated: Staff did not provide adequate ALWP accommodations to resident in care

This is an amended report t to clarify the facts of the original report issued 12-19-2023. At 9:40 a.m. Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced complaint visit to this facility to investigate the above allegation. LPA met with Vanissa Campbell, Staff #1 (S1), who granted access to the facility upon arrival. The Administrator, Amy Esrtsian, arrived shortly after and LPA explained the reason for the visit. Entrance interview conducted. At 10:00am, LPA requested copies of documentation which include, but not limited to Admission Agreement dated 11/30/2022 and Appraisal Needs and Services Plan. At 10:15 am, LPA conducted a physical plant tour. From 10:30am – 11:20am, LPA interviewed the Administrator, two (2) staff, and five (5) residents. Substantiated Allegation:Staff did not provide adequate ALWP accommodations to resident in care Based on interviews and observations resident # 1 (R1) was moved temporarily from their private room to a shared room due to repairs/remolding without prior written notice on or about 11/15/2023. Per review of R1’s admissions agreement R1 is entitled to a private room. LPA conducted interviews with the Administrator and staff who admitted to relocating R1 from their own private room to a shared room with another resident from 12-06-2023 to 12-13-2023. On 12/06/2023, the administrator admits new resident and instead of giving R1 back their original private room as repairs were completed the new resident was given R1’s room. The allegation is substantiated. The Administrator should have returned R1 to their original room once repairs were completed and not given it to the newly admitted. Deficiency cited on LIC 9099D. Exit interview conducted. Appeal rights and copy of this report issued.the state’s words, verbatim · CDSS document, Dec 19, 2023 · control 31-AS-20231214153230

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 19, 2023

87468.1(a)(3)Personal Rights of Residents in All Facilities....Residential care facilities for the elderly.... the following personal rights:To be free from punishment...... daily living functions..... eating, sleeping, or elimination. This requirement is not met as evidence by Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by not accommodating R1 with their private room after the repair as promised which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Administrator moved R1 to room # 4 on 12/13/2023. The move was completed prior to completion of the visit. *****Citation corrected at time of visit******

Allegation investigated: Staff are not ensuring the resident is taking medication as prescribed.

At 9:30 am, Licensing Program Analysts (LPAs) Angela Panushkina, and Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with Vanissa Campbell, Staff #1 (S1), who granted access to the facility. Shortly after, Designee and the Licensee of the facility arrived, and LPAs explained the reason for the visit. During course of the investigation, interviews and record review were made. At 9:40am, LPAs requested resident and staff roster. At 09:50am, LPAs requested copies of pertinent information which include, but not limited to Medication Policy, Centrally Stored Medication and Destruction Records (CSMDR) for Resident #1 (R1) and R2, Staff training etc., relevant to the investigation. At approximately 10:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 11:00am – 12:30pm, LPA conducted an interview with the Licensee and Designee, one (1) staff and four (4) residents. Continue on LIC9099-C Substantiated It was reported that the facility Staff are not ensuring the resident is taking medication as prescribed. To investigate this allegation, LPAs conducted an interview with Licensee, Designee and S1. All parties informed LPAs that four (4) out of four (4) residents receive their medications as prescribed and every time the medication is given to the resident, facility staff initials it on a Medication Administration Record (MAR). In addition, LPAs conducted interviews with four (4) out of four (4) residents and all residents confirmed that they receive their medications as prescribed. During today's visit, LPAs reviewed the facility Centrally Stored Medication and Destruction Record (CSMDR) of the random residents receiving medication assistance by the facility staff. Upon review of the medications LPAs observed that two(2) out of two (2) randomly chosen prescribed medications were centrally stored by the facility, however, they were not properly documented on CSMDR. LPAs observed R2’s two (2) medications (Divalproex Sodium and Lithium Carbonate) were prescribed to be administered/given as of 11/01/23, however, both medications were not delivered/received by the facility. Moreover, interview with the Licensee, Designee and S1 confirmed that after acknowledging that the medications were not received, the facility did not report to the Pharmacy, Hospice Agency, Doctor, etc. regarding this matter. Although, two medications were prescribed to R2 as of 11/01/23, LPAs confirmed during todays visit, that R2 missed nine (9) days of prescribed medications, which poses a immediate health and safety risk to residents in care. Based on inspection, record reviews and interviews this allegation is deemed Substantiated. Deficiency cited on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered. It was reported that the facility Staff do not clean residents room.To investigated this allegation, LPAs conducted an interview with Staff #1 (S1) and were informed that on a daily bases the rooms are cleaned by taking out the trash, fixing the bed (change sheets if needed), dusting and organizing the room. A deep clean is also done on a daily bases, which includes vacuuming the room, cleaning the bathroom, changing the bed sheets, and any other maintenance the room may require. At 10:30am, LPAs toured resident rooms #2, #3 and #4. All the rooms appeared to be clean and free of debris. The rooms appeared to be lived in and they were well maintained. Interviews with four (4) out of four (4) residents confirmed that their rooms are being cleaned daily. Based on interviews and LPAs observation, there is not enough evidence to support the above allegation. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 31-AS-20231108143829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 10, 2023

87465 Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above by not assuring that R2's prescibed medications were delivered timely and administered to R2 as prescribed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Administrator will order the missing medications from the pharmacy and notify doctor regarding the incident. Administrator will also submitt an incident report regarding the 9 day medication error. Administrator agreed to schedule vendorized training for all staff by 11/10/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

Allegation investigated: Staff refused to provide meals to resident in care Staff did not treat resident with respect

At 9:30 am, Licensing Program Analysts (LPAs) Angela Panushkina, and Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with Amy Eritsian and Kristina and LPAs explained the reason for the visit. During course of the investigation, interviews and record review were made. At 9:45am, LPAs requested resident and staff roster. At 10:50am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Staff training etc., relevant to the investigation. At approximately 11:55am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 11 am – 12:30pm, LPA interviewed the Licensee and Administrator designee, one (1) staff and four (4) residents. Continue on LIC9099-C Unsubstantiated Allegation: Staff refused to provide meals to resident in care. It was alleged that staff do not provide meals to residents in care. To investigate this allegation LPAs conducted interviews with Licensee, Designee and one (1) Staff member and were informed that the facility provides three (3) balanced meals and snacks in between and that all residents have full access to the food in the kitchen. Moreover, LPAs were informed that the facility staff will not violate resident's personal rights and will never deny food services to residents. LPAs were also informed that during R1's stay at this facility, R1 would refuse food and request a family member to buy and deliver a fast food every other day. In addition, LPAs conducted interviews with four (4) out of four (4) residents and all four (4) residents denied the above allegation. All residents informed LPAs that the facility always offers/provides three meals and snacks in between and that they do have access to the kitchen and an option to request for an extra food is always available. All residents also denied ever witnessing S1 refusing to provide meals to R1. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time. Allegation:Staff did not treat resident with respect. It was alleged that the staff do not treat resident with respect. To investigate this allegation LPAs conducted interviews with Licensee and Designee, and one (1) Staff member and were informed that staff always take care of resident with dignity and respect. On the other hand, LPAs were informed that during R1's stay at the facility R1 refused to follow facility house rules and disrespect staff and other residents. During the interview with S1 it was also revealed that on 10/27/23, at 10:40pm, R1 pushed S1 while calling him/her racial slur and 9-1-1 was called and a report was filed. In addition, interviews with four (4) out of four (4) residents revealed that they are being treated very well and with respect by all facility staff members. Interview with R2 revealed that during R1's stay here R2 was very traumatized by R1 approach and behavior. LPAs were informed that R1 would bully R2. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time. No deficiencies cited during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 31-AS-20231101104055