Ano One Facility for the Elderly

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The Administrator arrived at the facility shortly thereafter. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The common area was observed to be relatively clean and properly furnished. All required postings were observed. Exits have functioning auditory devices. The fire alarm/ carbon monoxide detectors were tested and functioned properly. Medications and first aid kits are located in a locked hallway closet. The LPA observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways and passages. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 118.6 degrees Fahrenheit. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside a kitchen cabinet, and a hallway closet. The LPA observed the fire extinguisher to be fully charged and last serviced on . BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and three (3) bathrooms for resident's use. The LPA observed residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C… RESTROOMS: Three (3) restrooms were observed to be relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. Water temperature measured at 116.8-degree Fahrenheit. OUTDOOR SPACE: The LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. Passageways were free and clear from obstruction. The facility has an accessory dwelling unit (ADU) at the back of the facility and is not part of the license. The ADU remains inaccessible to residents. RECORDS: Records review began at 12:15 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. All files were in order. MEDICATIONS: Medications review began at 1:15 p.m.; medications are centrally stored and locked in a cabinet located inside the locked linen closet; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. 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. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 14, 2026

Allegation investigated: Staff spoke inappropriately to resident in care.

Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegation listed above. The LPA met with the Administrator Artur Atoyan and explained the reason for the visit. LPA Urena, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. LPA Urena interviewed staff and residents at approximately 11:30 a.m. and reviewed records pertinent to the investigation. Continues on LIC 9099C... Unsubstantiated Staff spoke inappropriately to resident in care. On the allegation that facility staff spoke inappropriately to resident in care, it is alleged that facility staff told a resident to “go back into their room” after the resident had been standing in the hallway for approximately 10 minutes. To investigate the allegation LPA Urena interviewed the residents, staff and the Administrator. The residents reported that they are well taken care of by facility staff and staff have never been disrespectful. Furthermore, the residents reported that they can always be out of their room and anywhere they want in the facility without anyone telling them they can’t be there. The staff stated that they are always respectful towards residents. The Administrator stated staff are always respectful and would never tell residents that they are not allowed in the common areas of the facility. Based on the information received through the interviews there is not sufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 29-AS-20260716140008

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The Administrator arrived at the facility shortly thereafter. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The common area to be relatively clean and properly furnished. All required postings were observed. Exits have functioning auditory devices. The fire alarm/ carbon monoxide detectors were tested and functioned properly. Medications and first aid kits are located in a locked hallway closet. The LPA observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways and passages. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 118.6 degrees Fahrenheit. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside a kitchen cabinet, and a hallway closet. The LPA observed the fire extinguisher to be fully charged and last serviced on 07/15/2025. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and three (3) bathrooms for resident's use. The LPA observed residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C… RESTROOMS: Three restrooms were observed to be relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. Water temperature measured at 116.8-degree Fahrenheit. OUTDOOR SPACE: The LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. Passageways were free and clear from obstruction. The facility has an accessory dwelling unit (ADU) at the back of the facility and is not part of the license. The ADU remains inaccessible to residents. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster Due to time constraints, a continuation inspection is required. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The Administrator arrived at the facility shortly thereafter. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The common area to be relatively clean and properly furnished. All required postings were observed. Exits have functioning auditory devices. The fire alarm/ carbon monoxide detectors were tested and functioned properly. Medications and first aid kits are located in a locked hallway closet. The LPA observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways and passages. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 118.6 degrees Fahrenheit. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside a kitchen cabinet, and a hallway closet. The LPA observed the fire extinguisher to be fully charged and last serviced on 06/02/2024. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and three (3) bathrooms for resident's use. The LPA observed residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C… RESTROOMS: Three restrooms were observed to be relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. Water temperature measured at 116.8-degree Fahrenheit. OUTDOOR SPACE: The LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. Passageways were free and clear from obstruction. The facility has an accessory dwelling unit (ADU) at the back of the facility and is not part of the license. The ADU remains inaccessible to residents. RECORDS: Records review began at 12:15 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. All files were in order. MEDICATIONS: Medications review began at 1:15 p.m.; medications are centrally stored and locked in a cabinet located inside the locked linen closet; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. 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. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 23, 2024

Allegation investigated: Staff failed to administer resident’s medication as prescribed.

Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent visit to deliver findings at this facility. At 1:30 p.m., the LPA met with Administrator and explained the reason for the visit. During the initial visit on 08/17/2021, between 11:25 a.m. and 4:30 p.m., LPA Peraldi toured the facility, reviewed resident records and medications. During a subsequent visit, on 08/25/2021 between 9:30 a.m. to 5:00 p.m., LPA Peraldi and LPA Ashley Smith toured the facility, interviewed four (4) staff, including the Administrator, reviewed records and medications. During a subsequent visit on 05/19/2023 between 12:30 p.m. and 1:45 p.m., LPA Peraldi conducted a brief physical plant tout, conducted interviews with four (4) out of five (5) residents and with one (1) staff. Continued on LIC 9099-C. Substantiated Regarding the allegations: Staff failed to administer resident’s medication as prescribed. It was alleged that staff failed to properly assist residents with the self-administration of medication as prescribed. During a subsequent visit, LPAs Peraldi and Smith conducted a review of medication and medication documentation with the Administrators and observed the following: Resident #2’s (R2’s) Carbidopa-Levodopa (sp) per directions from physician, was to be administered four (4) times a day. However, the Medication Administration Record (MAR) confirmed that the Administrators were assisting with the self-administration of this medication three (3) times a day. The Administrators explained that R2 would refuse one (1) tablet of the medication and would only take the medication three (3) times a day. Based on the observation and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, and California Health and Safety Code the following deficiency were cited (refer to LIC 9099-D). Failure to correct the deficiency may result in civil penalty. Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegations: Staff neglect resulting in resident's poor hygiene. Staff are not meeting residents’ incontinence needs. It was alleged that staff neglected Resident #1 (R1) hygiene and are not meeting R1’s incontinence needs. Interviews with staff revealed that residents, including R1 are bathed twice a week. Interviews with staff revealed that majority of residents wear diapers and that staff change resident’s diapers two (2) to three (3) times a day. Interview with Administrator revealed that R1 has a catheter and that R1 is on Home Health services. R1’s Home Health continues to monitor R1’s catheter and staff continue to tend to R1’s catheter within the scope of their care. During the physical plant tour on 8/17/2021, 08/25/2021 and 05/19/2023, residents appeared well groomed. The LPA’s did not smell any odors nor did residents indicate that staff are neglectful. Additionally, resident interviews did not reveal any issues with their incontinence needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to assist residents with diabetes care. It was alleged that staff failed to assist residents with diabetes care. During the interview with the Administrator, it was revealed that two (2) out of five (5) residents, including R1 require assistance with diabetes care. The Administrator stated that staff supervise and assist the two residents with their diabetes care, including blood sugar check. The Administrator stated that the two residents can inject the insulin pen on their own. Interviews with residents did not reveal any issues with staff neglect towards diabetes care. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 29-AS-20210809155552

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 29, 2023

87465 (a) (4) Incidental Medical and Dental Care...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, record review, the licensee did not comply with the section cited above as R2’s medication of Carbidopa-Levodopa (sp) was not being assisted per directions from physician which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Within 24 hours, the Licensee will notify LPA when training will be completed. Licensee agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 08/16/2023. At 9:30 a.m., the LPA met with the Administrators and explained the reason for the visit. RECORD REVIEW: Between 9:45 a.m. to 11:10 a.m., the LPA reviewed resident records for five (5) out of five (5) residents. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All files were in order. The LPA conducted a personnel file review for all staff regularly scheduled and reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. At 3:00 p.m., the LPA conducted a review of medication and medication documentation with the Administrator for five (5) residents and observed that all medications were properly documented. Copy of valid liability insurance and Facility Emergency Plan was provided to the LPA during the visit. No deficiencies cited at this time. Exit interview conducted. A copy of the report of provided.the state’s words, verbatim · CDSS document, Sep 28, 2023