All Star Care

Type of visit: Required - 1 Year

On 5/19/2026 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the staff and stated the reason for their visit. The Administrator, Iveta Darabedyan arrived shortly after to assist with today’s visit. LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted: The facility is a single-story building with five (5) bedrooms and three (3) bathrooms. The facility is currently occupying four (4) residents. There is a designated staff room and staff bathroom. The facility has an approved fire clearance for six (6) non-ambulatory residents of which one (1) may be bedridden. Hospice waiver approved for six (6). Common areas: The living room and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 73°F. LPA observed a fire extinguisher to be located near the kitchen and purchase receipt of 01/17/2026. LPA observed required postings such as Long-Term Care Ombudsman, Emergency Disaster Plan, and Personal Rights to be located alongside the common areas. A working telephone was observed. LPA observed the fireplace to be covered and inaccessible to residents. Auditory alarms were observed throughout all entrances/exits of the facility. (continued on LIC 809-C) Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives/sharps were observed to be kept in a locked kitchen drawer. The cleaning solutions/toxins were observed to be kept locked underneath the kitchen sink. Kitchen appliances were observed to be working and in proper condition. Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed to be stored in cabinets located within the hallway’s passageway. Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. Staff Room: LPA observed the staff room to be locked and inaccessible to residents. Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. LPA observed there to be a locked shed/bathroom. There is no body of water located at the facility. Laundry Room: The laundry room was observed to be kept locked and located near the garage. LPA observed cleaning solutions and toxins stored appropriately within the laundry room and inaccessible to residents. The laundry appliances were observed to be working and in proper condition. Garage: The garage can be accessed from inside of the facility and located near the laundry room. The garage was observed to be kept locked and used for storage purposes. Medications: The medications were observed to be kept locked and located within a kitchen island cabinet. First-aid kit observed and First-Aid Manuel. Smoke detectors and carbon monoxide observed to be working properly and were tested. Residents/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of three (3) staff records. Staff records appeared to be complete and updated. There were no immediate health and safety hazards observed during the day of inspection. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 19, 2026

Allegation investigated: Staff are in violation of residents’ personal rights. Uncleared adults are supervising residents. Licensee does not ensure the Egress alarms are properly working.

On 1/21/2026 at approximately 9:15 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Administrator, Iveta Darabedyan arrived shortly after to assist with today’s visit. To investigate the allegation(s), at approximately 09:30 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation. From 10:30 AM to 01:00 PM, LPA attempted interviews with five (5) residents (R1-R5), two (2) staff members (S1-S2) and conducted record review. (contiue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff are in violation of residents’ personal rights. It was alleged that staff have violated residents’ personal rights. To investigate the allegation, LPA attempted interviews with five (5) residents and two (2) staff members. LPA’s interview with three (3) of the five (5) residents denied staff locking them in their room/bed, leaving them unattended and taking away their personal belongings. LPA attempted to interview R4 and R5 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with both staff members revealed that a former staff member, who has been terminated but refuses to leave the premises, has caused issues among staff and residents. LPA’s interview with S1 revealed they are in the process with the courts to take care of the matter and have ensured that the residents will not be left alone with said ex-employee. During LPA’s physical plant tour, LPA observed S2 to be present and assisting the residents. LPA did not observe the residents to be left alone or unattended. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Uncleared adults are supervising residents. It was alleged that staff members were working without obtaining proper background clearance. To investigate the allegation, LPA conducted interviews with three (3) residents and two (2) staff members. LPA’s interview with all three (3) residents revealed there are two (2) main caregivers (S2 and S3). LPA’s interview with S1 revealed that a former staff member, who was mentioned by the Reporting Party (RP), is no longer employed by the facility. LPA’s interview with all three (3) residents and two (2) staff members declined that an additional staff member, mentioned by the RP, has not worked at the facility. LPA conducted record review of the following documentation: Personnel Report, Department of Social Services Guardian Background Check System and Licensing Information System (LIS). LPA’s record review confirmed that the six (6) staff members listed on all documents had background clearance and were associated to the facility, including S1, S2 and S3. Based on interviews, observations and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (continue to LIC 9099-C) Regarding the allegation: Licensee does not ensure the Egress alarms are properly working. It was alleged that the facility’s auditory alarms were not working. To investigate the allegation, LPA conducted a physical plant tour. LPA observed a total of two (2) auditory alarms. One located in the front entrance/exit and the other located on the sliding door exit leading towards the backyard. LPA observed both to be functional and in proper condition. LPA observed both auditory alarms to signal when the doors would open. LPA attempted to observe room 5, which has an exit door per the facility sketch, but LPA observed room 5 to be locked. Per S1, room 5 is being occupied by the ex-employee who will not leave the facility. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator. Regarding the allegation: Staff do not follow proper medication management protocol. It was alleged that staff were administering medication to residents without a physician’s order. To investigate the allegation, LPA conducted interviews with three (3) residents and two (2) staff members. LPA’s interview with all three (3) residents revealed that staff have not given them unprescribed medication nor have they witnessed that to be done so. LPA’s interview with both staff members confirmed that all resident’s medications are centrally stored, locked and given as prescribed. However, during LPA’s physical plant, LPA observed R2’s medication to be accessible within the fridge and not locked. LPA observed medications to be stored in multiple areas of the refrigerator. LPA observed R2’s medication to be stored within a zip lock bag located where the perishable foods are kept. Additionally, LPA observed an unprescribed medication to be within a glass bottle wrapped in aluminon foil stored on the second shelf behind the food containers. In addition, LPA observed an unprescribed medication bottle to be located on the door of the refrigerator. LPA’s interview with S1 revealed that R2’s medication is to be locked in a container within the fridge and was unsure how their medication ended up outside of said container. Based on observation and interviews, LPA observed R2’s medication not locked and accessible to residents in care as well as unprescribed medication, therefore the allegation is SUBSTANTIATED, at this time. Citation issued, Please refer to 9099-D. No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 31-AS-20260114144418

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 22, 2026

87465 Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored:...(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons... This requirement was not met by: Based on interviews and observation, medications were not locked and were left accessible within the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: The Administer will review the regulation and email LPA Segovia a statement of understanding along with photos of residents’ medication locked and inaccessible to persons in care.

Allegation investigated: Facility is in financial distress

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. LPA was greeted by the two caregivers. LPA spoke to the Administrator, Iveta Darabedyan by phone at 10:45 am. LPA Spaeth stated the purpose of the visit was to present the complaint findings. LPA and the caregiver toured the facility at 10:50 am until 11:00 am. LPA observed there are four residents living in the facility. The investigation consisted of the following: On 6/06/2024, LPA Spaeth conducted a 10-day visit and observed there were no residents in the facility. Continued on 9099-C Unsubstantiated Regarding the allegation: Facility is in financial distress: It’s being alleged the facility is financially struggling. LPA Spaeth interviewed the Administrator today at 10:45 am who stated there are four residents living in the facility and all rent payments have been received. LPA reviewed the resident’s records and observed Admissions Agreements state the monthly payment amounts. During LPA’s facility tour, LPA observed a sufficient supply of food and other supplies necessary to ensure the care of the residents. Based upon LPA’s interview, review of residents’ records, and observations, the allegation is unsubstantiated. Exit interview conducted and a copy of the report was giventhe state’s words, verbatim · CDSS document, Jun 27, 2025 · control 31-AS-20240602100413

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by two caregivers. LPA spoke to the Administrator, Iveta Darabedyan by phone. LPA stated the purpose of the visit was to review residents' files and tour the facility. LPA reviewed the residents' files at 10:45 am until 11:10 am. LPA toured the facility at 11:10 am until 11:50 am. At 11:20 am, LPA observed the front door and back door delayed egress devices were not working. Also, the delayed egress device in Room 3 was weak and could not be heard. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to caregiverthe state’s words, verbatim · CDSS document, May 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 88705(k) · Plan of correction due date: May 2, 2025

88705 Care of persons with Dementia (k) The following initial & continuing requirements must be met...to utilize delayed egress devices on exterior doors or perimeter fence gates. This is evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed the delayed egress alarms had been turned off at the front door and back door. The alarm in Room 3 had a weak alarm notification, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: During LPA's visit, the front door and back door egress devices were turned on. The device in Room 3 was repaired and was properly working.

Type of visit: Required - 1 Year

On 3/13/2025 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and LPA stated the reason for their visit. Administrator Iveta Darabedyan arrived shortly after to assist with today’s visit. LPA asked for the census and Staff/Resident Roster. LPA conducted a physical plant tour at approximately 11:30 AM and the following was noted: The facility is a single unit building with five (5) bedrooms and three (3) bathrooms currently occupying three (3) residents. There is one (1) designated staff room with one (1) private bathroom. The facility has an approved fire clearance for six (6) non-ambulatory residents, one (1) of which may be bedridden. The facility has an approved Hospice waiver for six (6) residents. Sign in sheet, hand sanitizer, gloves and masks are available. LPA observed required posting such as See/Say Something, Long-Term Ombudsman, and Facility Sketch located immediately upon entrance. Common areas: These include the living room, the dining room, and Staff Office. All rooms were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 71°F. A fireplace was observed to be covered and inaccessible to residents. A working telephone was observed. Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives and sharps were observed to be kept in a locked cabinet near the kitchen stove. LPA observed cleaning solutions and toxins to be kept locked underneath kitchen sink inaccessible to residents. Kitchen appliances were observed to be working and in proper condition. LPA observed a fire extinguisher to be located near the kitchen and dated 03/13/25. (continued on LIC 809-C) Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed stored in a storage closet located in the hallway’s passageway. Bathrooms: The bathrooms were checked for cleanliness and proper operation. Appropriate grab rails and non-slip mats were observed and in proper condition. The hot water temperature was measured within regulations. Garage: The garage can be accessed from inside of the facility and was observed to be kept locked and inaccessible to residents. Laundry Room: The laundry room is located near the garage. LPA observed laundry room to be kept locked and cleaning solutions properly stored within laundry room and inaccessible to residents. Laundry appliances observed to be working and in proper condition. Staff Room: LPA observed staff room locked and inaccessible to residents. Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water located at the facility. Medications: Medications were observed to be kept in a locked cabinet located in the kitchen. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and First Aid manual. The Smoke detectors and carbon monoxides were observed to be working properly and were tested. Residents/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. There were no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Office

An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional office. The purpose of this Informal Conference is to discuss the incident that occurred during the month of April, 2024. Present at today's meeting are the following: · Troy Agard, Licensing Program Manager (LPM) · Melissa Spaeth, Licensing Program Analyst (LPA) · Iveta Darabedyan – Administrator/Licensee The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. BRIEF HISTORY: Facility has been in operation since licensure on 5/15/2023 and is licensed for six non-ambulatory residents, one of which may be bedridden. A complaint was received by CCL on 6/02/2024. Licensing Program Analyst (LPA) Melissa Spaeth initiated a complaint investigation on 6/06/2024, arrived at the facility at 9:45 am and stated the purpose of the visit was to investigate a complaint. Continued on 809-C LPA Spaeth and the Licensee toured the facility at 10:00 am to 10:15 am. LPA observed there were no residents living in the facility. The Licensee stated there were four residents living in the facility. However, the residents moved out during the month of April, 2024. LPA Spaeth requested to review the residents’ documents. The Administrator stated they did not obtain all the required documentation when the residents moved into the facility. The Administrator stated a verbal eviction notice was given to all four residents but not a written notification. LPM Agard discussed and expressed concerns regarding the April, 2024 incident. LPM Agard also expressed concerns that the Administrator failed to obtain the required resident documentation and failed to give the residents a written eviction notice. The Licensee was informed that Community Care Licensing (CCL) shall continue to frequently monitor the facility as often as necessary to ensure the Licensee's compliance with Title 22 Regulations Exit interview conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 11, 2024

Allegation investigated: Residents were illegally evicted Staff did not report facility status to the department

On 06/06/2024 Licensing Program Analyst (LPA) Melissa Spaeth initiated a complaint investigation for the allegation(s) listed above and met with the Administrator Iveta Darabedyan. LPA Spaeth explained the purpose of this visit is to gather information regarding the complaint allegations. The Administrator confirmed there are currently no residents within the facility. LPA Spaeth toured the facility at 10:00 am until 10:15 am and did not observe residents living in the facility, LPA Spaeth requested to review the following documents: 1) residents' documentation, and 2) residents' eviction notices. The Administrator stated they did not obtain all the required documentation when the residents moved into the facility. LPA interviewed the Administrator at 10:20 am until 11:30 am. Continued on 9099-C Substantiated The investigation revealed the following: Regarding the allegation, residents were illegally evicted. It’s being alleged residents were not given a written 30-day eviction notice. The Administrator stated a verbal notice was given to all four residents but not a written notification. Regarding the allegation, Staff did not report facility status to the department. It’s being alleged that the four residents (R1, R2, R3, and R4) were transferred to another licensed facility and the Administrator did not inform Community Care Licensing about the transfer. The Administrator stated R1, R2, and R3 were transferred to a licensed facility on 4/30/2024 because the residents were not happy. On 4/29/2024, R4 informed the Administrator they did not feel well and R4 was transferred to a local hospital. LPA Spaeth spoke to R4’s family member via phone call at 11:45 am who confirmed R4 was transferred to a local hospital. LPA asked if the Administrator had reported the transfer of residents to another facility to Community Care Licensing. The Administrator stated no. Based upon the Administrator’s interview, the above allegations, residents were illegally evicted and staff did not report facility status to the department are substantiated. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 6, 2024 · control 31-AS-20240602100413

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Jun 7, 2024

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required....This is evidenced by: Based upon LPA's interview of the Licensee, the licensee failed to issue a written thirty day written notice to the residents. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2024

Plan of correction: The Administrator will review regulation 87224 and send an email to LPA Spaeth confirming the Administrator did review the regulation

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 7, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1)A written report shall be submitted to the licensing agency…(D) Any incident which threatens the welfare, safety, or health of any resident…This is evidenced by: Based upon LPA's interview of the LIcensee, the licensee failed to report to the Department that R1, R2, and R3 moved to another licensed facility and R4 was transported to the hospitalthe state’s words, verbatim · CDSS document, Jun 6, 2024

Plan of correction: The Administrator will review regulation 87211 and send an email to LPA Spaeth confirming the Administrator did review the regulation

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 - Deficiencies

On 06/06/2024 Licensing Program Analyst (LPA) Melissa Spaeth initiated a complaint investigation for Complaint #31-AS-20240602100413. LPA Spaeth requested to review the resident's files. However, the Administrator stated they were unable to obtain the required documentation from the residents. LPA stated to the Administrator it is important to obtain all documentation before the move-in date. The Administrator stated they will make sure all documentation is obtained when admitting any resident. Based upon LPA's observation and interview of the Administrator, the following deficiency will be issued. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Jun 7, 2024

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...This is evidenced by: The Licensee failed to obtain resident records for each resident living in the facility. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2024

Plan of correction: The Administrator will review regulation 87506 and send an email to LPA Spaeth confirming the Administrator did review the regulation.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) year Required visit at this facility. LPA met with the administrator Iveta Darabedyan and explained the purpose of this visit. A tour of the physical plant was conducted at 9:26 AM and the following was observed: The facility has one main entrance being used. The PPE screening station is located immediately upon entrance and had a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. The facility has an approved mitigation and infection control plan on file. The facility is a single storey building and has five (5) bedrooms and three (3) bathrooms. An additional room is being used as an office and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #5. Hospice waiver for six (6) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 73°F. The dual smoke/carbon monoxide alarm are hardwired and interconnected and observed to be operational. There is a Fire extinguisher is located in the kitchen and observed to be full and current. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. (continued on LIC 809-C) (continued from LIC 809) Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry area is located in bedroom hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked inside the laundry room. The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked and measured at a range of 106.3°F to 111.1°F. Towels and washcloths are not shared. There were enough clean linen available in stock at the cabinet. Medications: LPA observed that the medication are kept in the cabinet in the island cabinet in the kitchen and was observed to be locked and inaccessible to residents. There was a complete first aid kit located on top of the medication cabinet. Garage: The garage has access from inside the facility and also being used as PPE, tools and other supplies storage. The garage was observed to be locked. The Backyard had a covered shaded area for clients with outdoor furniture. There is no body of water at the facility. Client records. There is no resident at the facility at this time. Staff records were also reviewed. Staff records was reviewed, staff have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current. Required posting observed in facility (complaint hot line poster, personal rights, etc). Exit interview conducted. Copy of this report issuedthe state’s words, verbatim · CDSS document, May 25, 2024

Allegation investigated: Staff withheld food from residents in care

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint investigation and met with Administrator Iveta Darabeyan, who was informed the reason of the visit. The following was determined during the visit. It was alleged staff withheld food from residents in care. To investigate this matter, from 10:15am to 2pm, LPA conducted interviews with residents and staff and conducted a physical plant inspection of the kitchen area and the facility’s food. LPA observed the facility met Licensing requirements for perishable and non-perishable; but interviews reported the facility does not provide an adequate amount of food for meals. During today’s visit, LPA observed residents eating (1) hamburger for lunch. LPA also observed staff giving residents a piece of candy, 3 cookies, and a piece of banana. The quantity or variety was insufficient, and residents reported not getting enough food. LPA also observed the facility had locks on cabinets where food was kept. This is an immediate health and safety risk to residents in care. Therefore, based on observations and interviews the allegation is Substantiated Substantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 31-AS-20240202164342

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Feb 13, 2024

General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board...This requirement was not met, evidenced by: Based on observations and interviews, the facility does not provide an adequate amount of food for meals. This is a immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: The Administrator will train and meet with staff on providing enough meals for the residents; as well as discussing appropriate snacks. Administrator will email LPA when training and discussion with staff take place.