Anthem Senior Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required Annual visit. The LPA met with staff and explained the reason for the visit. Staff reported that the Administrator is out sick and is unable to come to the facility. Staff Armen Ghazarya arrived to the facility to assist LPA with the visit. The LPA toured the physical plant areas inside and outside, with the staff to ensure there are no health and safety hazards. BEDROOMS: There are (4) four bedrooms designated for resident use and (1) one staff room. Bedrooms observed appropriate furnished, sufficient lighting, and clean linens. RESTROOMS: The Resident restrooms observed clean, sanitary, and in operating condition with grab bars and non-skid surfaces; sufficient amounts of soap and paper products. Hot water measured in the bathrooms between 107.4 and 109.8 degrees Fahrenheit. KITCHEN: Sufficient supply of perishable food and nonperishable food observed. Knives, medications, and chemicals observed locked and inaccessible. Appliances observed clean and operable. COMMON AREAS: The common spaces included the living room and dining area. The LPA observed cameras in all common spaces and a screened fireplace in the living room. All areas were clean, sanitary and in good repair. The LPA observed required postings on the living room wall. One fire extinguisher was observed to be fully charged and serviced on 06/10/2026. Smoke detectors and Carbon Monoxide detectors were tested and observed functioning properly. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use and a small laundry area. There were no bodies of water noted. The garage is attached to the house but has been converted to a separate living quarters with a separate address. Two additional storage space observed locked; storage space is used for supplies, emergency food and other items. Due to time constraints, annual inspection will continue at a later date. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Jun 17, 2026

Allegation investigated: Staff physically assaulted resident which resulted in injuries

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 12:20PM and met with the Administrator Sofiya Ghazaryan and explained the reason for the visit. Entrance interview conducted. On 08/08/2024, LPA Christine Yee conducted an initial complaint visit at 11:45AM. Between 12:01PM and 2:43PM, LPA Yee interviewed the Administrator, two (2) staff, two (2) residents, and attempted one (1) resident interview. Additionally, LPA Yee conducted a safety tour and observed the facility’s food supply. Report Continued on LIC 9099-C Unsubstantiated On 11/19/2025, LPA Huynh conducted a subsequent visit. Between 10AM and 10:40AM, LPA Huynh conducted a physical plant tour, interviewed the Administrator, one (1) staff, two (2) residents, and attempted four (4) resident interviews. Beginning at 11:09AM, the LPA conducted a medication review. During today’s visit, the LPA and Administrator conducted a physical plant tour at 12:28PM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff physically assaulted resident which resulted in injuries” It was reported that facility staff physically assaulted Resident #1 (R1), allegedly resulting in lacerations and bruises. Interview with four (4) residents revealed that staff treat them respectfully and meet their care needs. They denied experiencing physical abuse and stated they had not observed staff mistreating R1. Staff were observed to assist R1 with showers, feeding, and incontinence care. R1 was unable to participate in an interview due to medical condition. Interview with staff stated they provide care in accordance with residents’ care plans and requests for additional accommodation. They confirmed they do not yell at the residents, though they raise their voices when communicating with residents who are hard of hearing. Staff further reported they do not become frustrated or physical with residents. Physician’s Report dated 02/04/2025 documented R1 to be non-ambulatory with bed bound status and a diagnosis of Huntington’s Disease. Hospice Care Plan initiated on 06/16/2025 indicated R1 remained bed bound and received two (2) Home Health Aide visits per week. R1’s Appraisal/Needs and Services Plan dated 01/28/2025 reported R1 had limited functioning and required full assistance with activities of daily living. Based on interview and record review, although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 29-AS-20240807145031

Allegation investigated: Staff inappropriately restrained resident to the bed to prevent them from getting up Staff are chemically restraining resident Staff did not treat resident with dignity and respect Staff did not provide adequate food service

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced subsequent complaint visit for the above allegations. The LPA arrived at 9:47AM and met with the Administrator Sofiya Ghazaryan and explained the reason for the visit. Entrance interview conducted. On 08/08/2024, LPA Christine Yee conducted an initial complaint visit at 11:45AM. Between 12:01PM and 2:43PM, LPA Yee interviewed the Administrator, two (2) staff, two (2) residents, and attempted one (1) resident interview. Additionally, LPA Yee conducted a safety tour and observed the facility’s food supply. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, between 10AM and 10:40AM, LPA Huynh conducted a safety tour, interviewed the Administrator, one (1) staff, two (2) residents, and attempted four (4) resident interviews. Beginning at 11:09AM, the LPA conducted a medication review. No immediate concerns were observed, and medication errors were documented on a Case Management report. The following was then determined: Allegations: “Staff inappropriately restrained resident to the bed to prevent them from getting up,” “Staff are chemically restraining resident,” “Staff did not treat resident with dignity and respect,” “Staff did not provide adequate food service.” It was reported that facility Staff restrained Resident #1 (R1) to their bed physically and by utilizing sleeping aids, and do not treat Residents with respect or provide Residents meals when requested. Interview with three (3) Residents revealed that they have not experienced or observed Staff physically restrain Residents to their beds. Resident #2 (R2) stated R1 was previously their roommate and did not observe any mistreatment from the Staff. Resident #3 (R3) and Resident #4 (R4) both confirmed physical restraints have not been used on R1. Three (3) out of three (3) Residents reported that staff care is good, are respectful, and do not typically raise their voice at the Residents. R4 noted that they have experienced staff raising their voices when R4 had accidents, but Staff were instructing R4 to prevent future accidents. Additionally, Residents reported receiving meals throughout the day with R2 noting they are never left hungry. Overall, Residents had no concerns regarding staff treatment and level of care provided. Interview with the Administrator and two (2) Staff revealed that Staff do not utilize restraints or yell at the Residents. Staff #1 (S1) reported that they raise their voices occasionally when they are communicating with Residents who are hard of hearing. S1 noted that Staff try their best to accommodate Resident requests which include food services and S1 understands the importance of their role to provide care and comfort to the Residents due to their health conditions. S1 and Staff #2 (S2) assist the Residents with most of their Activities of Daily Living (ADL), which include cleaning, cooking, showering, transfers, and medication management. Report Continued on LIC 9099-C The Administrator and Staff reported that meals are served as followed: Breakfast is served between 8:30AM and 9AM or when the Residents wake up, Lunch is served between 1PM and 1:30PM, Dinner is served between 5:30PM and 6PM, and snacks are offered between each meal and upon Resident requests. Facility grocery shopping occurs twice a week and Residents receive home cooked meals. The facility’s food supply was observed to be sufficient and of good quality. Medication review revealed that Residents were prescribed sleeping aids: R1, R3, and Resident #5 (R5) were prescribed Temazepam and R4 was prescribed Trazadone with each dosage accounted for on the facility’s Medication Administration Record and Centrally Stored Medication and Destruction Record. LPA Huynh did not observe additional storage of prescribed medications or Over The Counter (OTC) medications. Resident medications are administered twice a day in the Morning and at Bedtime. Additionally, R1, R2, and R4 receive medication administration in the Afternoon. R1’s Physician’s Report dated 02/04/2024 indicated R1 was diagnosed with Huntington’s Disease, Anxiety Disorder, Depression, and Schizophrenia. R1 was documented to be Non-Ambulatory with bed bound status, minimally responsive, and required maximum assistance in all ADLs. R1’s Physician’s Report dated 03/10/2025 documented R1 to be Bedridden. Based on interviews and record review, although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency related to the allegations cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 29-AS-20240807145031

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20240807145031. The LPA arrived at 9:47AM and met with the Administrator Sofiya Ghazaryan and explained the reason for the visit. Entrance interview conducted. During today’s visit, between 10AM and 10:40AM, LPA Huynh conducted a safety tour, interviewed the Administrator, one (1) staff, two (2) residents, and attempted four (4) resident interviews. Beginning at 11:09AM, the LPA conducted a medication review. During the medication review, the LPA observed five (5) out of six (6) Residents did not have a current Centrally Stored Medication and Destruction Record for medications filled and delivered between 11/10/2025 and 11/13/2025. The Administrator stated they have not had the opportunity to work on the record yet. The Administrator will update them and provide them to the LPA. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Nov 26, 2025

(a) A plan for incidental medical and dental care shall be developed by each facility… (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above in 5 out of 6 residents' centrally stored medication and destruction records were not maintained which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: The Administrator will update 5 Residents' medication records and provide them to CCLD by POC due date.

Allegation investigated: . Facility staff did not ensure resident's incontinenance care needs were met 2. Facility staff did not communicate resident's health history/health condition to medical personnel

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and was let into the home by Armenuhi Khosteghyan, Staff and met with Sofiya Ghazaryan, Administrator. The reason for today's visit was provided. On today's visit LPA Yee conducted an interview with the Administrator at 11:08am, Staff #2 at 12:11pm, Resident #3 at 1:18pm and Resident #5 at 1:32pm. LPA Yee attempted to interview Resident #2 at 1:42pm and couldn't understand what the resident was saying. Staff #1 was not present during the incident involving Resident #1 and was not interviewed separately. Resident #3 and Resident #6 are non-verbal and were not interviewed. Resident #1 is still hospitalized and was not interviewed. Resident #1's file was reviewed at 12:45pm Continued on LIC9099-C Unsubstantiated Page 2. Per information received from the interviews conducted, Staff #2 checked on Resident #1 around 7:15am on the morning of 10/2/25 and found the resident in bed vomiting and covered in blood. Staff #2 turned the resident on to their side to prevent the resident from choking from the vomit. Staff #2 immediately called the Administrator to advise her about Resident #1. Staff #2 was going to clean Resident #1 but was told by the Administrator not to touch the resident and to immediately call 911. Per the Administrator, she called 911 from her home and explained the situation to the 911 operator. The 911 operator obtained the facility telephone number and conference called Staff #2. Staff #2 was asked about Resident #1's breathing and Staff #2 indicated that the resident's breathing was quiet. Per Staff #2, the resident moaned every time they vomited. Per the Administrator, she lives a short distance away from the home and got in her vehicle and headed to the facility. Per Staff #2, the paramedics arrived around 7:30am and she showed them to Resident #1's room. Per Staff #2 the paramedic checked Resident #1's neck for a pulse and said that resident was dying. They wrapped Resident #1 in the bedsheets and transferred the resident to the gurney that was outside the room. The paramedic again stated that Resident #1 was dying. They asked the staff for the resident's identification to obtain their age and the insurance card. They did not ask for any paperwork or list of medication because they wanted to get Resident #1 to the hospital. Per the Administrator, she got to the corner of the street and saw the paramedics and was able to get the name of the hospital that the resident was being transported to. Per the Administrator, she had a doctor appointment at 8:30am that morning and then went directly to the hospital and got there around 10/10:30am. Per the investigation regarding the allegation that facility staff did not ensure resident's incontinence care needs were met, the investigation revealed that Resident #1 was restless during the night and staff had checked on Resident #1 around 3am. Per Staff #2, Resident #1 was sleeping soundly and didn't need to be changed. Everything was fine. Per Staff #1 and Staff #2, they check on the residents at night regularly and when they hear the residents making noises. Per Staff #2, on the morning of 10/2/25, they were going to change Resident #1 when they observed that the resident was vomiting and covered in blood and then she was told not to touch the resident due to the urgency to obtain emergency services for the resident. Per Staff #2, the soiled diaper was not dry, it was still wet when she wanted to change the resident. Per continued on LIC9099-C Page 3. interviews conducted with Resident #3 and Resident #5, the staff change the residents timely. Per Resident #5, they are able to use the bathroom themselves but use a pull up for accidents. Per information obtained from the interviews conducted, there is insufficient evidence to support the allegation that facility staff did not ensure resident's incontinence care needs were met. Although the allegation may have happened or is valid, there is insufficient evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. Per interviews conducted with the Administrator regarding the allegation that facility staff did not communicate resident's health history/health condition to medical personnel, information revealed that the facility does provide emergency personnel with resident's identification, insurance card, a list of medication and medical information. Per Staff #2, on 10/2/25 the paramedics only asked for the residents identification to determine the resident's age and the insurance card and due to the resident vomiting blood, rushed Resident #1 to the hospital. They did not ask for any thing else or ask any questions. Per interview with the Administrator, when she was done with her doctor appointment on 10/2/25, she went to the hospital. When she got there, Resident #1 was still in the emergency room. Bleeding had stopped, resident was cleaned up and had an MRI. The MRI results were pending. Per the Administrator, she had provided the nurse with information regarding the resident's spinal issues and a copy of the residents medications that she had picked up from the facility and the nurse indicated that they didn't need it because the resident was on IV. Per the Administrator, she left a medication list with the ICU nurse and the Pharmacist wrote down the Resident's medications. Per information obtained from the interviews conducted, there is insufficient evidence to support the allegation that facility staff did not ensure resident's incontinence care needs were met. Although the allegation may have happened or is valid, there is insufficient evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. Exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 29-AS-20251006110845

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. When the LPA arrived, there was one staff present. The LPA was greeted by Caregiver, Armenuhi Ahadzhanian and informed the reason for the visit. Caregiver contacted the Administrator by phone, Sofia Ghazaryan. At 10:17 A.M. administrator arrived at the facility. LPA explained the reason for the visit. At 10:25 A.M. the LPA, along with administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed. Facility is a single-story residence that consists of four (4) resident bedrooms and two (2) bathrooms. There is one (1) additional bedroom and bathroom for staff use. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Bedrooms: All resident resident’s bedrooms were properly furnished with at least one chair, a bed, night stand, chests of drawers, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Continued on LIC 809-C Continued from LIC 809 Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The LPA observed grab bars and slip resistant floors in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. Between 10:31 A.M. and 10:45 A.M. hot water was measured in all residents’ bathrooms. All bathrooms were within the required limit of 105-120 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 74 degrees. The LPA observed the required postings in the entry way and common sitting area. Combination smoke alarms and carbon monoxide detectors were tested at 3:02 P.M. and were operational at this time. LPA observed a fully charged fire extinguisher serviced on 10/23/2023. Technical violation issued under maintenance and operations. LPA observed cameras in common areas. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects were stored in a kitchen drawer located to the right of the oven. During today’s visit, the magnetic lock on the drawer was not functioning properly and failed to keep drawer securely locked. The administrator stated that the lock is malfunctioning and acknowledged that it needs to be replaced. Furthermore, LPA observed a glass cup containing stainless steel knifes stored inside an unlocked kitchen cabinet. Additionally, an unlocked medication injection was observed inside the kitchen refrigerator. At 10:53 A.M. hot water measured at 105.7 degrees Fahrenheit. Garage: The facility has converted the garage into a separate living space which has its own address. Continued on LIC 809-C Continued from LIC 809-C Surrounding Grounds (Outdoors): The backyard has a covered outdoor area equipped with furniture for resident use and a small laundry area. There were no bodies of water noted. The front yard is free of obstructions, the side gate has a self-latching door. Additionally, the LPA observed a back house with two (2) rooms. Upon entering the first room, the LPA observed that it was being used as an office and storage area. The room contained extra food supplies, a refrigerator, and emergency food and water provisions. LPA conducted a review of expiration dates on product labels. The LPA observed that three (3) items were past their expiration date. Administrator discarded all three (3) items during today’s visit. Technical Advice Issued. The second room was locked, however, upon entry, the LPA observed that it contained chemical supplies, tools, and various decorations. File review: A review of facility files was initiate at 11:23 A.M. and the following was observed. LPA reviewed five (5) of five (5) residents files and three (3) staff file including the administrator’s. Files were reviewed for, but not limited to: Physician's Reports, Personal Rights, Admission Agreements, staff training records, health screenings, TB tests, and background clearance. Record review of resident files revealed that Resident #1’s (R1)’s physicians report, dated 02/04/2024 indicating R1 not having capacity for selfcare and R1 is neither under hospice care nor have an approved exception on file with the Department. Furthermore, LPA observed that of the five (5) residents currently residing at the facility, three (3) are non-ambulatory, one (1) is bedridden and one (1) is ambulatory. Continued on LIC 809-C Continued from LIC 809-C The facility’s fire clearance on file, dated on 01/05/2016, only authorizes care for four (4) ambulatory residents, one (1) non-ambulatory and one (1) bedridden resident. According to the clearance, only Room #3 is approved to accommodate residents who are non-ambulatory or bedridden. During the plant tour, LPA observed that bedridden resident (Resident #1 -R1) was placed in room #2, non-ambulatory resident (R2) was placed in room #1, and Resident #5 (R5) was placed in the former activity room which are not designated for such use. The Administrator stated that a new fire clearance was granted in 2023, however, she was unable to present the document at the time of the visit. LPA attempted to contact the fire inspector to verify the updated clearance but was unable to confirm this information. Also, LPA observed R3 did not have a current hospice care plan on file. Additionally, R2 and R3 were observed to have full bed rails installed on their beds, however, there were no physician’s orders were on record. Administrator was able to provide this information during today’s visit. Furthermore, R1, a former hospice patient who is no longer under hospice care was observed to have f ull bed rails in place. No current physician’s order was available to support the continued used of the full bedrails. During staff record review, LPA observed that Administrator (Ad), Staff #1 (S1) and Staff #2 (S2) did not have current CPR/First aid certificate. The administrator is the SSI payee for R1 and surety bond is current. LPA requested last emergency drill; however, Administration was unable to provide it. LPA obtained Client Roster, Personnel Report, liability insurance and updated facility Sketch. Continued on LIC 809-C Continued from LIC 809-C Medication Audit: Medications review began at 3:24 P.M. medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. LPA observed errors during the medication review where date started and pill count did not match. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 is assessed today due to being cited for fire clearance. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 12, 2025

Allegation investigated: . Staff hit resident 2. Staff yelled at resident 3. Staff did not treat resident with respect

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegations. The purpose of this visit is to deliver findings for the above listed allegations. Upon arrival at 10:00 a.m., LPA Mosley was greeted by staff and Administrator. The LPA met with Administrator, Sofia Ghazaryan. On 05/06/2024 the Department received a complaint regarding the following allegations Staff hit resident, Staff yelled at resident, and Staff did not treat resident with respect. On 05/15/2024 LPA Yee conducted the initial 10-day complaint visit. LPA reviewed and obtained a copy of Resident #1's (R1) file, interviewed the Administrator at 11:18am, Staff #1 (S1) and Staff #2 (S2) at 12:46pm, R1 at 12:26pm, Resident #2 (R2) at 1:14pm and re-interviewed R1 at 1:22pm with the assistance of a translator. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (Page 2) Report continued from LIC 9099... During today’s visit, starting at 10:10 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 10:30 a.m. LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however was denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, Department of Mental Health Case Worker (DMHCW), Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1s relative and emergency contact that R1 does not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation. On the allegation Staff hit resident it is the concern of the reporting party (RP) that facility staff hit R1 on the back and shoulder area. To investigate this complaint, LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however was denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, DMHCW, Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1 relative and emergency contact they do not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation. Interview with current residents revealed that they have never been hit by staff. They have never witnessed a staff member hit a resident. They did not witness or hear staff hit R1. Interviews with staff including the Administrator revealed that they are unfamiliar and unaware of any staff ever hitting any of the residents. The staff would never hit any of the residents. Staff were knowledgeable in reporting procedures when LPA Mosley asked questions regarding reporting abuse. Interviews with relative and emergency contact for R1 revealed that they are currently unaware of where R1 is at because R1 recently left the hospital and does not have a cell phone. Report continued on LIC 9099-C PAGE 3... (Page 3) Report continued from LIC9099-C Page 2... They did not witness any of the staff hit R1 on the shoulder or back. They have never witnessed any of the staff hitting a resident. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff hit resident is deemed unsubstantiated at this time. On the allegation Staff yelled at resident it is the concern of the reporting party (RP) that facility staff yelled at R1 because they decided to shower at 4.a.m. To investigate this complaint, LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, DMHCW, Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1’s relative and emergency contact that R1 does not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation. Interviews with current residents residing at the facility revealed the staff do not yell at them. The staff at times may need to raise their voice to the residents since some residents are hard of hearing but they are not yelled at. Residents did not see staff yell at R1 and did not witness staff yell at R1. LPA did speak louder as both residents stated they could not hear LPA and ask LPA to speak louder. Interviews with staff including the Administrator revealed that staff do not yell at the residents. At times staff will speak to the residents louder because they can not hear very well. The staff have never yelled at any of the residents and the staff do not yell at the residents. The staff did not yell at R1. Interview with R1’s relative and emergency contact revealed that R1 can be difficult to work with and did not follow the facility rules at time. The relative had a conversation with R1 about the staff’s cultural background and how it can be a factor as to why they may speak louder and may not be yelling. The relative never witnessed any of the staff yelling and never witnessed the staff yell at R1. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff yelled at resident is deemed unsubstantiated at this time. Report continued on LIC 9099-C PAGE 4... (Page 4) Report continued from LIC9099-C Page 3... On the allegation Staff did not treat resident with respect it is the concern of the reporting party (RP) that facility staff did not treat R1 with respect and entered the bathroom while they were showering. To investigate this complaint, LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, DMHCW, Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1’s relative and emergency contact that R1 does not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation. Interviews with current residents revealed that they have not had any issues with showering. The staff do not enter the bathroom while residents are showering. They have never experienced staff entering the bathroom while they are showering. They have never witnessed the staff entering the bathroom while another resident was showering. They have never witnessed staff entering the bathroom on R1 while showering. The staff treat them with respect and dignity. Interviews with staff revealed that they have never entered the bathroom while a resident was showering. The staff respect the residents and give them their privacy while using the bathroom. The staff did not enter the bathroom while R1 was showering. The facility respects all their residents and treats them all with dignity and respect. Interviews with R1’s relative and emergency contact revealed that R1 was always clean and well taken care. They did not witness the facility staff mistreat R1 or deny R1 respect. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not treat resident with respect is deemed unsubstantiated at this time. No deficiencies were observed or cited during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, May 28, 2025 · control 29-AS-20240506113433

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies observed during a visit to the facility today. LPA Yee met with Sofia Ghazaryan, Administrator. The reason for today's visit was explained. On today's visit, it was observed during file review that Resident #1, Resident #4 and Resident #5 are on hospice and the Department was not notified of the initiation of hospice services. Per tour of the facility, the front door was observed with an operational auditory device and the back outside exiting doors located in bedroom #4 and the glass sliding door did not have any auditory devices and bedroom #3 had a auditory device that was not operational. Resident #1, who is on hospice, does not have a care plan in place and there is no written evidence that staff have received the appropriate training for the care of the resident. Resident #2's hospital bed is not functioning and the needs to be replaced. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, APPEALS RIGHTS discussed and a copy was given.the state’s words, verbatim · CDSS document, Aug 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(j) · Plan of correction due date: Aug 15, 2024

Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced per tour of the facilit, it was observed that bedroom #4 an back sliding glass door did not have an auditory device installed on the door and the auditory device on bedroom #3 had a auditory device that was no operationalthe state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Licensee will ensure that all outside exiting doors have auditory devices that will monitor and alert staff when a resident leaves the facility by 8/15/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(a)(4) · Plan of correction due date: Aug 15, 2024

Hospice Care of Terminally Ill Residents: The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill...and receive hospice services from a hospice agency in the facility when all of the following conditions are met: A written hospice care plan specifies the care, services and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each resident...prior to the initiation of hospice services in the facility for that resident, Resident #1 does not have a care planthe state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Licensee will review Title 22, Sections 87632 and 87633 and provide a signed written statement that the sections were read and understood and will be adhered to. Licensee will also contact the Hospice agency for Resident #1 and any other resident's hospice agency to obtain any and all necessary documentation needed and maintain in the residents' files. Provide evidence by 8/15/24 that the files have been updated and contain all the required documentation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 15, 2024

Maintenance and Operation:The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Resident #2's hospital bed was observed to be non-operational and could not to be lowered or raised to allow easy access into bed and replace the mattress as needed since it was observed propped by bedding below the mattress and the full rail needs to be removed.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Licensee will have the hospital bed repaired or replaced to allow the resident easy access into bed and a mattress in good condition is provided and the full bed rail is removed. Provide evidence that all the above corrections have been made by 8/15/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Aug 15, 2024

Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: The licensee shall notify the Department in writing within five working days of the initiation of hospice care.....The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Dept not notified of R1, R4 & R's hospice initiationthe state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Licensee will review Title 22, Section 87632 and 1. submit a statement that the section was read and understood and will be adhered to 2. Licensee will submit hospice initiation letters for Resident #1, Resident #4 and Resident #5 by 8/15/24

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Sofia Ghazaryan, Administrator. The reason for today's visit was provided. The facility is a single storey family home consisting of a living room, dining room, kitchen, 5 bedrooms of which one bedroom is used for live in staff, 2 common bathrooms and 1 staff bathroom. The facility is fire cleared for 4 AMBULATORY, 1 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #3 is approved for bedridden use. Due to time constraints none of the domains were reviewed on today's visit. 3 resident files were reviewed. Based on file review: Resident #1 does not have a signed medical consent form, has an incomplete Appraisal/Needs and services and inventory of valuables Resident #2 has an incomplete Appraisal/Needs and Services Resident #3 does not have a signed medical consent form and a incomplete Appraisal/Needs and Services. The Licensee is the SSI payee for Resident #3 and the facility does not have a surety bond. Due to time constraints, deficiencies observed on today's visit will be cited on a return visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 24, 2024