Ararat Gardens

Type of visit: Required - 1 Year

On 5/09/2026 at approximately 10:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Wellness Director, Najwa Elwan 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 02:00 PM and the following was noted: The facility is a multi-story building. The facility has a capacity of one hundred seventy-five (175) residents. The facility is currently occupying eight-five (85) residents. The facility has an approved fire clearance for one hundred (100) ambulatory residents, seventy (70) non-ambulatory residents of which five (5) may be bedridden. Hospice waiver approved for fourteen (14). Common areas: The common areas include such areas as: Dining room, Beauty shop, Library, Theater, Fitness room, and Activities Rooms. The common areas 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 between 72°F-75°F. The hallways and passageways were observed to be free of obstruction. The stairways were observed to be equipped with evacuation chairs. LPA observed there to be two (2) elevators which were observed to be functional. LPA observed multiple fire extinguishers to be located throughout the facility on all levels and dated 4/16/2026. LPA observed required postings such as Long-Term Care Ombudsman, See/Say Something and Facility’s license to be located throughout the common areas. Office/Work Station: The Administrative offices were observed to be located on the main lobby floor. (continued on LIC 809-C) Kitchen: The kitchen was observed to be clean and free from pests. The kitchen was observed to be a commercial kitchen with a variety of commercial-grade appliances and fixtures such as but not limited to: high-capacity gas ranges, convection ovens, fryers and stainless-steel prep tables. LPA observed the kitchen appliances to be working and in proper condition. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Outside: LPA observed there to be a variety of courtyards equipped with sufficient seating and shaded areas for residents to use. There is no body of water located at the facility. Laundry Room: LPA observed there to be a commercial laundry room. Laundry detergents, cleaning agents and other toxins are locked away. Bathrooms: LPA observed a variety of public restrooms located throughout the facility. The bathrooms within the residents’ rooms were checked for cleanliness and proper operation. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. The hot water temperature was measured at a range of 116.4°F-118.6°F. Bedrooms: The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Medication Room: LPA observed the medication room to be located on the first floor. LPA observed the medications to be properly stored within locked medication carts and inaccessible to residents. The medication usage was observed to be recorded and stored properly. LPA along with a care staff conducted a review of the medication to ensure compliance. First-aid kit was observed. Smoke detectors and carbon monoxide: The facility was last inspected for maintenance and operational use of their automatic sprinkler system on 03/01/2026. The facility is scheduled for inspection of maintenance and operational use of all fire alarms on 5/13/2026. The last Fire Drill was conducted on 04/01/2026. Residents/Staff Records: LPA conducted a complete file review of ten (10) resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of seven (7) 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 Wellness Director.the state’s words, verbatim · CDSS document, May 9, 2026

Allegation investigated: Staff did not seek timely medical attention for resident. Staff neglect resulted in resident developing a pressure injury. Staff did not ensure resident received adequate nutrition. Staff did not ensure comfortable living accommodations were provided for resident.

Licensing Program Analysts (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit to the facility to investigate the above allegation. LPA met with the Wellness Director (S2), Najwa Elwan, and advised them about the visit. An entrance interview was conducted. To investigate the allegation on 1.21.2026 at 1:09 PM, LPA conducted a physical plant tour to ensure the health and safety of the clients in care. LPA interviewed thirteen (13) out of eighty-one (81) residents from 1:09 PM until 2:00 PM. LPA interviewed the executive director and four (4) staff who were present at the facility from 12:40 PM to 1:08 PM. LPA reviewed the residents’ records from 2:05 PM to 2:30 PM. During initial visit LPA Ngo-Castaneda also received and reviewed copies of documents related to the Continue to LIC 9099-C Unsubstantiated investigation, including, but not limited to staff and resident roster, residents’ physician’s report, admissions agreement, appraisals, need and service plan and other documents. After the initial visit, LPA requested and received R1’s medical records from the hospital, and they were reviewed on February 3, 2026. Allegation #1: Staff did not seek timely medical attention for resident. It was alleged that facility staff did not seek medical attention in a timely manner for resident #1 (R1’s) altered mental status. LPA review of R1's file revealed the following: R1 was assessed and admitted to the facility on October 15, 2025; LPA interview with executive director (ED) and other staff revealed that R1 and all the residents are receiving adequate care and supervision by facility staff, and that 911 emergency service calls are made by staff if necessary. LPA interviews with thirteen (13) out of eighty-one (81) residents state that staff provide satisfactory care and supervision. R1’s physician's report does not identify that R1 had altered mental condition. A review of hospital medical records also did not provide any information to support the allegation. Therefore, based on LPA interviews and record review, the allegation is Unsubstantiated at this time. Allegation #2: Staff neglect resulted in resident developing a pressure injury. It was alleged that R1 developed a pressure injury while in care at the facility. ED and other staff indicated that R1 had no pressure injuries. A review of R1’s facility file and hospital records did not provide any information to verify that R1 developed pressure injuries. There was no indication that R1 developed any pressure injury. The information available during this investigation does not verify the allegation. Therefore, based on interviews and record review and due to lack of supporting evidence, the allegation is unsubstantiated at this time. Continue to LIC 9099-C Allegation #3: Staff did not ensure resident received adequate nutrition. It was alleged that the facility was not providing adequate nutrition for R1 which led to R1 losing weight. During LPA’s visits, it was observed that the facility offers a well-balanced, nutritious meal throughout the day with various options. During interviews with staff, all staff stated they not only fed the residents and provided the same meals as everyone else but also offered additional food according to residents' preferences and dietary restrictions. Staff always encourage and assist residents to finish their meal. During interviews with residents, all residents stated they are served three (03) meals a day and that snacks are available throughout the day. During an interview with a third-party witness, they stated that residents loved the food at the facility and did not suspect any malnutrition or inconsistencies while visiting the facility. A review of the R1 medical records from the hospital did not indicate that the resident was malnourished. Based on interviews, observations, and record review, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. Allegation #4: Staff did not ensure comfortable living accommodations were provided for resident. It was alleged that staff do not provide comfortable living accommodation in R1's bedroom. R1 resided in bedroom #12, and it was observed that R1 had all required furniture. Everything was functional and comfortable. LPA's observation of other residents bedrooms revealed that the facility residents have preferences for their living accommodations and staff is trying to accommodate them to the best of their ability. LPA interview with the staff revealed that every resident has their own preferences and up to date they have not received any complaints from any resident about their living arrangements. Residents revealed that they did not have any problem with the living accommodation in their respective rooms. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. Exit interview conducted. A copy of this report was given to the Wellness director (S2).the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 31-AS-20260115145239

Allegation investigated: Staff did not provide assistance for a resident to use the restroom

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced initial visit for the above allegation. LPA met with wellness director (S1) Najwa Elwan and explained the reason for the visit. Allegation: Staff did not provide assistance for a resident to use the restroom It is alleged that on 1.30.2026 staff did not assist Resident#1 (R1) to use the bathroom. To investigate the allegation, with the assistance of the wellness director (S1) at 11:50 AM, LPA took a tour of the physical plant. During this investigation, at 12:30 PM, LPA interviewed the wellness director (S1) and six (6) other staff members. LPA interview with R1 today at 1:42 PM, revealed that staff left R1 left soaked or soiled for a long time. Continue to LIC 9099-C Unsubstantiated At 1:52 PM LPA conducted a records review of R1's file, included but not limited to call log for residents assistance, physician's report, appraisal needs and services plan and other relevant documents. LPA interview with nine (9) incontinent residents today revealed that staff change them regularly and check on them regularly all the time. Residents also revealed that they are assisted immediately and are changed when requested. LPA interview with staff confirmed that they changed R1 and other incontinent residents regularly four (4) to five (5) times a day during their shift and check on them everyone and a half (1 1/2) hours to two (2) hours. LPA review of residents call log revealed that residents are being assisted within 5-7 minutes. Based on interviews, LPAs observations and record review, there is no sufficient information to verify the allegation. Therefore, this allegation is deemed Unsubstantiated, at this time. Exit interview is conducted and a copy of this report given to wellness director (S1).the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 31-AS-20260130153412

Allegation investigated: Resident receiving additional incidental medical care unrelated to their health condition. Facility staff bully resident.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced initial visit for the above allegation. LPA met with Executive Director Varsenik Keshishyan and explained the reason for the visit. Allegation #1: Resident receiving additional incidental medical care unrelated to their health condition. It is alleged that Resident#1 (R1) was given a medical referral to the specialist for medical care unrelated to their health condition. To investigate the allegation, With the assistance of the administrator at 10:00AM, LPA took a tour of the physical plant. At 9:30 AM, LPA interviewed the executive director (S1) and four (4) other staff members. Continue to LIC 9099-C Unsubstantiated At 10:22 AM, LPA interviewed a total of ten (10) residents, including R1. At 9:45AM LPA conducted a records review of R1's file, as well as other relevant documents, including the physician's report, admission agreement, LIC 500, resident roster, appraisal needs and services, intake sheet, and other pertinent documents. Staff , revealed, that residents are referred to the medical specialist to get incidental medical care based on their health conditions or other related information warranting additional referrals to the skilled professionals. Nine (9) out of ten (10) residents, stated that facility staff always offer them assistance that is related to their medical care based on available information, overall assessment, and changes in their condition. A review of medical record revealed that the R1 was referred to the skilled professional due to the information they received from the 3rd party who provided assistance to the R1 outside of facility. Based on observation, interviews and record review, although this allegation may have occurred, there is not sufficient information to verify validity of the complaint. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Allegation #2: Facility staff bully resident. It was alleged that resident #1 (R1) spoke inappropriately and was bullied by staff #2 (S2). To investigate the allegation, LPA conducted a physical plant tour at around 10:00 AM. From 9:30AM to 2:00 PM, LPA interviewed the executive director (S1), four (04) staff, and ten (10) residents. At 10:15 AM, LPA interviewed a total of ten (10) residents, including R1. At 2:10 PM LPA conducted a records review of R1's file, as well as other relevant documents, including the physician's report, admission agreement, LIC 500, resident roster, appraisal needs and services, intake sheet, and other pertinent documents, including internal incident log. Staff revealed that they have never bullied or speak inappropriately to a resident and treats all residents with dignity and respect. Interview with nine (9) out of ten (10) residents revealed that they are happy living at the facility and that the overall staff are nice to them. No residents addressed any issues and concerns regarding S2. Residents also stated that S2 knows how to communicate with them and at time S2 may be firm if needed. Continue to LIC 9099-C Based on interviews and review of facility records did not reveal any information to support the allegation. Therefore, based on interviews, observation and record review, the allegation is deemed UNSUBSTANTIATED at this time. No health and safety issues were noted at the time of this visit. An exit interview was conducted, and a copy of the report was issued to the ED.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 31-AS-20250822155313

Allegation investigated: Staff did not ensure facility was kept clean, safe, and sanitary

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with KESHISHYAN, VARSENIK, who is the executive director, and explained the reason for the visit. Allegation: Staff did not ensure the facility was kept clean, safe, and sanitary. It was alleged that residents #1 (R1), who currently reside at the facility, has a strong odor coming from the bathroom. To investigate the allegation, LPA conducted a physical plant tour at around 9:50 AM, requested pertinent documents at 11:00 AM, and interviewed six (06) staff and eleven (11) residents between 9:53 AM to 01:51 PM. During the physical plant tour, LPA did not experience a malodor or observe any foul smell in the residents' bathroom, bedroom, carpets, or anywhere else in the facility. Continue to LIC 9099-C Unsubstantiated During interviews with the executive director and five (5) staff members, it was revealed that they are not aware of any foul-smelling odor within the facility. An interview with staff revealed that housekeeping cleans the residents' bedrooms once a week or more when requested. R1 reported being the only person able to smell the alleged odor. LPA inspected R1’s bathroom sink, shower, and toilet, and did not experience any foul smell. LPA interviewed four (4) residents on the floor and six (6) other residents within the facility. The interview revealed that they did not experience or encounter such an odor within the facility. Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 31-AS-20250801164041

Allegation investigated: Staff did not repsond to call signal system in a timely manner. Staff handled resident in a rough manner

Thiis is an amendment to the report previously issued on 04/16/2025. The report was amended to make corrections. On 4/16/25 Licensing Program Analyst (LPA) Leizl Delacerra conducted an unannounced initial complaint visit to this facility to investigate the allegations listed above. LPA met with Varsenik Keshishyan, Executive Director. LPA disclosed the purpose of the visit. On 5/13/2025 LPA de la Cerra conducted a subsequent complaint visit and met with the Executive Director for signature of the amended report. Copy of amended reprt wss provided to Executive Director. Allegation: Staff did not respond to call signal system in a timely manner. It was alleged that on the evening of 04/08/2025 that resident - R1 used their pull cord so they could get bathroom assistance, and facility staff did not respond to R1 in a timely manner, so R1 attempted to get out of bed on their own but slipped during their attempt. To investigate the allegation, on 04/16/2025 between 10:30am to 12:30pm LPA conducted a physical plant tour, interviewed four (04) staff members, and at 12:30pm to 2:30pm interviewed eight (08) out of Seventy-Five (75) residents including R1, requested police incident narrative, and conducted record reviews provided by the facility. Continue to LIC9099-C Unsubstantiated During physical plant tour, LPA De la Cerra pulled an emergency cord and staff responded within 4 minutes.Staff revealed that R1 or other residents are getting assistance immediately. Interviews conducted with R1, and seven (07) residents revealed that the facility staff responds to their calls in a timely manner. LPA’s review of the facility’s call signal response log revealed that R1's call signal button/pendant was pushed two (02) times on the evening of 4/08/2025. The times were, 7:51pm and 8:24pm. During the time R1 pushed the button on their call pendant at 7:51pm, 1st time staff responded within 1 minute and 21 seconds and the second time R1 the button on their call pendant was pushed at 8:24pm, log shows that it took 3 minutes and 09 seconds for the staff member to respond to R1. Based on observation, inspection and record review, the facility staff responded to resident’s emergency call within reasonable time frame. Therefore, this allegation is deemed Unsubstantiated. Allegation: Staff handled resident in a rough manner. It was alleged that on 04/08/2025 that resident - R1 fell/slipped on the floor during their attempt to get out of their bed and the facility staff who assisted R1 off the floor, handled R1 in a rough manner. To investigate the allegation, on 04/16/2025 between 10:30am to 12:30pm LPA conducted a physical plant tour, interviewed four (04) staff members, and at 12:30pm to 2:30pm interviewed eight (08) out of Seventy-Five (75) residents including R1, requested police incident narrative, and conducted record reviews provided by the facility. Interview with the staff member - S2 regarding the incident on 4/08/25 revealed that S2 requested assistance from another staff member - S3 to lift R1 off the floor. Both staff members, S2 and S3 informed LPA that R1 was not handled in a rough manner. Interviews with other staff members- S1 and S4 revealed that they have never witnessed neither S2 and S3 handled R1 or any other residents roughly. Interviews with other residents revealed that they have never been handled roughly by a staff member, nor they have witnessed neither S2 nor S3 handle any other residents roughly. Interview with R1 revealed that R1 was assisted by staff #2 (S2) and staff #3 (S3) on 4/08/25, R1 confirmed with LPA that S2 and S3 did not handle them in a rough manner when both staff lifted R1 off the floor. A review of the incident record provided by Glendale Police Department revealed that during their interview with R1 on 4/11/25, R1 did not mention about being handled in a rough manner on 4/08/25. Based on LPA observations, interviews and record reviews, this there is no sufficient information to verify the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. No health and safety issues were noted at the time of this visit. An exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 13, 2025 · control 31-AS-20250410153508

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Executive Director, Varsenik Keshishyan, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:30a.m. and the following was noted: There is one main entrance being utilized at the facility with reception to the immediate left. This is a multi-story property with a single level wing. The facility has a total of one hundred twenty-five (125) resident rooms each with its own bathroom. The facility is fire cleared for one hundred (100) ambulatory and seventy-five (75) non-ambulatory of which five (05) may be bedridden. The facility is currently occupying seventy-two (72) residents. The facility has multiple courtyards with outdoor furniture and shaded areas for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be inaccessible to residents. (continued on LIC 809-C) The common areas are neat and clean. The facility has a complete activities calendar and a designated activities area that is in the main lounge. The facility maintains an average comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized. Fire extinguishers are located throughout the facility and observed to be fully charged and last inspected 04/14/2025. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 113.2°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 30, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda met with Charles Brugh, Executive Director at 10:25 AM for a plan of correction visit. The purpose of the Plan of correction is to correct deficiencies issued last visit on 12.26.2024. Entrance interview conducted. Plan of correction visit: During the tour of the facility at 10:30AM. LPA requested that for the resident roster. LPA visited and confirmed residents who are in need of switching from ambulatory to non-ambulatory rooms. At 10:30 AM LPA toured bedrooms #2, #14, #111, #118, #119, #122, #123, #206, and #209. LPA observed the bedrooms to be clean and residents are happy with their new bedrooms. Plan of correction letters issued this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Jan 29, 2025

Allegation investigated: Facility is not following approved fire clearance for non-ambulatory residents.

Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda, Angelica Segovia, and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced initial complaint visit to the facility and met with the Interim Administrator (Charles Burgh- S1). It was alleged that non-ambulatory residents including resident #1 (R1) that are unable to ambulate without walker are residing on the second floor, which was not approved by The Fire Department. To investigate the allegation, at 12:30 PM LPM and LPAs spoke with ED and Residents Care Director (RCD). At 2:15 PM LPAs requested and reviewed the staff and resident roster and copies of facility records pertinent to the investigation. Records included but not limited to randomly selected residents’ physician’s report, and admissions agreement(s). Continue to LIC 9099-C Substantiated Upon Review of residents’ records, LPM and LPAs observed that there were non-ambulatory residents, including R1 were residing on the upper levels (between 2nd and 4th floors) of the building that was not approved to retain non-ambulatory residents. During this visit at 12:35 PM LPAs Ngo-Castaneda and Segovia, conducted a tour of physical plant. At 12:38PM LPAs interviewed ten (10) out if 70 randomly selected residents. Interview revealed that facility retains 10 or more non-ambulatory residents residing on the 2nd,3rd and 4th floor. The information revealed from the record review supported the information revealed from interviews. Based on inspection, observation, interviews and record review, there is a sufficient information and evidence to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Exit interview was conducted at which time ED was informed that due to violation of the same Title 22 Regulations within 12 months, additional immediate Civil Penalty of $1000,00 will be issued at the time of this visit. Exit interview was conducted, appeal rights were discussed, and a copy of report was issued,the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 31-AS-20241218135733

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202 · Plan of correction due date: Dec 27, 2024

87202-Fire Clearance -All facilities shall maintain a fire clearance approved by the city fire department..Prior to accepting or retaining.. non-ambulatory persons, the licensee shall notify the licensing agecy and obtain an appropiate fire clearance... This requirement was not met as evidenced by: Upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the 2nd to 4th floor. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: The ED will submit a plan for non-ambulatory residents to LPA. As well as request additional non-ambulatory file clearance for the second and third floor residents by submitting LIC 200 within 24 hours.

Type of visit: Case Management - Health Checks

Licensing Program Manager (LPM) Naira Margaryan, Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Angelica Segovia conducted unannounced Case Management: Health and Safety visit to the facility. LPM and LPAs met the Executive Director (ED) Charles Brugh and he was informed that this case management visit was conducted to discuss the recent visit conducted by the Fire Inspector from Glendale Fire Department. During Licensing Inspection conducted by the Department on 09/24/2024, it was noted that the facility retains non-ambulatory residents on the 2nd, 3rd and 4th floors without having appropriate approved fire clearance. The facility requested a new fire clearance to get approval for the upper levels. However, on 11/19/2024 the fire clearance was denied. Prior to this visit, Fire Inspector from GFD contacted community care Licensing Department and informed the following. “On 11/19/2024, Glendale Fire Department (GFD) performed an inspection at the facility. Upon review of the application, GFD has denied the request to increase the non-ambulatory and bedridden counts for this site. In addition, the applicant contacted the Fire Department and request to indicate that all 4 floors would be permitted to allow non-ambulatory and bedridden patients. GFD was unable to accommodate this request. Based on GFD inspection, all non-ambulatory and bedridden patients shall remain on the 1st floor as per Tittle 22 of CCR or have direct access to the outside from their rooms. Previous fire clearance indicates: Five (5) Bedridden. Seventy-five (75) non-ambulatory One hundred (100) ambulatory. In addition, it indicates that all rooms on the first floor are approved to be used for bedridden and/or non-ambulatory residents. According to fire inspector who visited the facility, modifications to bed counts on the first floor can be approved by Glendale Fire Department, as long as non-ambulatory and bedridden residents remain on the 1st floor. During this visit LPM Margaryan, LPAs Ngo- Castaneda and Segovia spoke with ED, and explained that at this time the facility is not in compliance with the Title 22 Regulation regarding approved Fire clearance. ED indicated that after the visit from the fire Department, RD and Executive Management are working on it and trying to determine how they are going to resolve this issue with minimal effect to residents that should be relocated to different rooms. The meeting was held with all residents, and they were informed about upcoming changes of residents’ rooms. Based on today’s residents Roster, there are more than ten (10) non-ambulatory residents residing on 2nd, 3rd and 4th floors. ED stated that they will start moving residents as soon as possible. No other immediate health and safety issues observed. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 26, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analysts ( LPA s) Rosaura Valenzuela, Leslie Ngo-Castaneda and Licensing Program Manager Naira Margaryan conducted an unannounced Case Management Visit to the facility and met with the Interim Administrator. LPA informed him that the purpose of this visit was to issue the citations and civil penalties for the deficiencies observed during the Licensing Visit. The following deficiencies were noted at the time of this Case Management Visit: Operating out of scope- Upon file review it as noted that facility is Implementing an "Independent Living Plus" program without having obtained prior approval from the Licensing Department Improper placement of residents- It was observed that non-ambulatory residents are being housed on the second and third floors. Fire clearance upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the second floor. No updated physician's report-Upon file review, it was noted that residents physician's reports and needs and services plan are not being updated as needed. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited (Refer to LIC 809-D). Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202 · Plan of correction due date: Sep 25, 2024

87202-Fire Clearance -All facilities shall maintain a fire clearance approved by the city fire department..Prior to accepting or retaining.. non-ambulatory persons, the licensee shall notify the licensing agecy and obtain an appropiate fire clearance... This requirement was not met as evidenced by: Upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the second floor. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: The Licensee will request additional non-ambulatory file clearance for the second and third floor residents by submitting LIC 200 and facility sketch within 24 hours.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87294(b) · Plan of correction due date: Oct 15, 2024

87204(b)-Limitations-Capacity and Ambulatory Status-Resident rooms approved for 24 hour care of ambulatory residents only shall not accommodate nonambulatory residents. Resdients whose conditon becomes nonambulatory shall not remain in rooms restricted to ambulatory residents, This requirement was not met as evidenced by: It was observed that non-ambulatory residents were residing in ambulatory rooms.This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: in addition to submission of LIC200 and facility sketch, Licensee will provide a written statement how they will ensure to met the limitations of capacity versus ambulatory status.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Oct 8, 2024

87208(a)-Plan of Operation-Each facility shall have and maintain a current, written definitive plan of operation. The plan and related mateials shall be on file in the facility and shall be submitted to licensing...Any significant changes in the plan of operation ...shall be submitted to licensing for approval. This requirement was not met as evidence by: Upon file review it as noted that facility is Implementing an"Independent Living Plus" program without having obtained prior approval from the Licensing Department This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: The Licensee shall submit in writing to Licensig an updated plan of operation by 10/08/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Oct 8, 2024

87463(a) Reappraisals-The pre-admission appraisal shall be submitted in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.,, This requirement was not met as evidenced by: it was noted that residents physician's reports and needs and services plan are not being updated as needed. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: The Licensee shall update all the medical records and needs and services plans of all residents in care by 10/08/2024.

Allegation investigated: Staff does not ensure resident's pendent and call button is in good repair.

On 7.24.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Edemida Vasque (S2) the License Vocational Nurse (LVN) of the facility; execitive director (ED-S1) was on maternity leave. At 10 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care. Allegation: Staff does not ensure resident's pendent and call button is in good repair. It was alleged that the facility staff did not respond to residents' pendants and emergency pull cords promptly. On 06.19.2024 LPA Leslie Ngo-Castaneda initiated this investigation into the complaint. Continue to LIC 9099-C Substantiated LPA requested and reviewed the staff roster, resident roster, residents’ physician’s report, admissions agreement, appraisals, and incident reports. LPA interviewed residents, fourteen (14) out of seventy-two (72) residents and six (6) out of twenty-five (25) staff. While interviewing residents, LPA randomly tested residents’ pendants and emergency call buttons in bathrooms and bedrooms. LPA conducted a random inspection of one (1) pendant one (1) emergency pull cords in the bathroom, and one (1) emergency pull cords in the bedroom. During the inspection one (1) pendant call was received by the facility and a caregiver responded to the call in eight (8) minutes and four (4) minutes consecutively. However, at 11:30 AM, LPA tested the residents' pendant and emergency cord in room #122 and waited until 11:50 AM. No staff showed up to reset the call buttons. Based on LPA's observation and review of the information received this allegation is Substantiated. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. Copy of this report issued. LPA interviewed the Executive Director, License Vocational Nurse (LVN), and R1 and it was revealed that paramedics were called immediately after responding to the call button in R1 bathroom in room #205. Furthermore, it was revealed that medical assistance such as calling 9-1-1 during an emergency has been used for all residents when needed. Resident interviews also revealed that they also have access to call 911 if they need to. Therefore, based on LPA observations, record reviews, and interviews this allegation is deemed Unsubstantiated. No health and safety issues were noted at the time of this visit. An exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 24, 2024 · control 31-AS-20240613104442

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Jul 25, 2024

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. Based on LPA inspection the licensee did not comply with the section cited above. Staff did not respond to 1 out of 3 emergency devices, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: The Licensee/Administrator provided in-service training to all staff. A copy of the training will be submitted to LPA. Cleared during LPA visit.

Type of visit: Case Management - Deficiencies

This case management visit is conducted by the Licensing Program Analyst (LPA) Leslie Ngo-Castaneda in conjunction with complaint investigation visit to address the issues unrelated to the complaint. On 6.19.2024 while LPA was conducting complaint investigation, LPA conducted a random inspection of one (1) pendant one (1) emergency pull cords in the bathroom, and one (1) emergency pull cords in the bedroom. During the inspection one (1) pendant call was received by the facility and a caregiver responded to the call in eight (8) minutes and four (4) minutes consecutively. However, at 11:30 AM, LPA tested the residents' pendant and emergency cord in room #122 and waited until 11:50 AM. No staff showed up to reset the call buttons. Therefore, based on the observation and interviews of three (3) out of six (6) staff admitted it was concluded that the facility has insufficient staffing. Under Title 22 Regulations, the following citation is issued and recorded on LIC809D. No immediate health and safety hazard is noted at the time of this visit. Exit interview was conducted. Appeal rights discussed and a copy of report was issued.the state’s words, verbatim · CDSS document, Jul 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 25, 2024

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation, record review and interviews conducted, facility staff failed to meet the needs of resident (R1) when call button was press.This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Cleared during visit. Two (2) new staff was hired and started today 7.24.2024 (Wednesday) and 7.26.2024 (Friday).

Type of visit: Case Management - Other

This Case Management Visit was conducted to address the issues discussed during the Annual Inspection. On 07/05/2024, the Woodland Hills Regional Office received information that the facility is implementing a new program called "Assisted Living +" . The residents requiring minimal care will be relocated from the Independent Living 3rd floor to the 2nd floor. Facility Executive Director (ED) Varsenik Keshishyan informed LPA Valenzuela that they already are implementing a new program and one of the residents, Resident #1 (R1) who was residing on the 3d floor recently moved to the 2nd floor. LPA Valenzuela contacted LPM Margaryan over the phone to discuss the recent changes within the facility structure and program plan. During the conference call between LPM Margaryan, (ED) Keshishyan, and LPA Valenzuela, LPM explained that while implementing the new procedures, ED should consider the resident personal rights to ensure that residents are in agreement to change their apartment units, due to the fact that minimal staff assistance could be provided to the residents in their existing units. ED informed LPM and LPA that R1's relocation was initiated based con R1's Power of Attorney (POA's) decision. LPM advised ED that POA does not reflect resident's' personal rights. If resident does not want to move from the independent living section to the Assisted Living+ section, then the facility should adhere to the residents wishes and allow them to stay in the apartment units that they originally choose. ED stated that she will discuss the recent relocation with R1 and if R1 wishes to move back to their previous room, then they will move R1 back to their previous room. LPA Valenzuela also advised the ED that it looks like they made changes in the facility program plan. The implementation of the new procedures must be submitted as an Addendum to the program plan to the Woodland Hills Regional Office so that it can be reviewed and updated to the facility file.the state’s words, verbatim · CDSS document, Jul 11, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced required 1-year annual inspection. LPA met with Executive Director Varsenik Keshishyan and explained the reason for the visit. The facility is located in a residential neighborhood. It is 4-stories in height with a lower level (LL). There is also a skilled nursing facility adjacent to the building. The facility has approximately 140 resident-bedrooms in total. Upon entry on the first floor, the concierge desk is directly to the right. Straight ahead is the main dining room/ lounge area and courtyard. The right hallway is the Assisted Living (AL) wing and the left hallway is the Independent Living (IL) wing. Residents bedrooms run throughout the facility on the 1st, 2nd, 3rd and 4th level. On the LL there is a laundry room, several activity rooms, a gym, movie cinema, beauty salon, private dining space and storage as well as some administrative offices. 1st floor contains several lounge/meeting areas, courtyard, dining, bistro, clinic for medications, kitchen, storage and library. The facility has a parking lot adjacent to the west wing of the building. The courtyard contains a covered patio. The facility fire clearance is maintained in conformity with State Fire Marshall regulations. The facility operates and is within capacity limits. Carbon monoxide and smoke detectors were tested and all were operable. No bodies of water were observed in or around the facility. The facility maintains a comfortable temperature. Hot water temperature was measured in the kitchen and in resident bathrooms and was within the required 105 degrees F and 120 degrees F. LPA observed the resident rooms to be properly furnished. Centrally stored medicines are kept in the medication room and are locked. There is a functioning call system in each residents' room. Outdoor and indoor passageways were observed to be free and clear of obstructions. Continue on 809-C Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. LPA observed there to be a minimum of one (1) week of nonperishable foods and two (2) days of perishable for the number of residents being served. Total daily diet has quality and quantity to meet resident's needs. Grab bars were available for each toilet, bathtub and shower used by residents. Bathtubs/showers have nonskid mats or strips and surfaces. There are five complete first aid kits. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Resident Rights (Provider refuses to honor existing Continuing Care Contracts)

Christina Hadley investigated the circumstances surrounding the allegation mentioned above. During the course of the investigtion the following information was determined: • On July 19, 2022 Residents of Windsor were provided with 120 Days’ Notice of Sale of CCRC Windsor per California Health & Safety Code 1789.4(d) • An acknowledgement of Assignment of Residency Agreement was drafted and shared with the resident association (Including the complainant) that outlines Ararat’s responsibility to provide residency, services and care as described in the agreement on and after the effective date of the sale to Ararat on March 1, 2023. An interview with the Executive Director reveals that the Provider (Ararat) is fully aware that as part of the sale, they are obligated to honor the existing continuing care contracts that were entered into by HumanGood dba Windsor. To date, there has not been evidence of the provider failing to fulfill its obligation to existing residents. A finding of UNFOUNDED, means that the allegation is false and/or without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 31-AS-20230811134454

Allegation investigated: Staff mishandled a resident while in care Staff threw a resident's soiled undergarment at their face while in care

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. It was alleged that Staff 1 (S1) was being rough while changing Resident 1 (R1). It was also alleged that S1 threw R1's soiled underwear at them. No injuries were reported and no witnesses identified. LPA met with the administrator, Varsenik Keshisyan, and advised her of the complaint. According to the administrator, this incident occurred at the Skilled Nursing (SN) portion of the campus. The administrator self reported the incident and submitted an SOC 341 to California Department of Public Health (CDPH), Ombudsman, and Law Enforcement (LE) on 03/27/24. CDPH and LE conducted their follow up visit on or around 03/28/24. SNF portion of the campus is overseen by CDPH. Because R1 resides at the SNF portion of the campus and the incident occurred there, and not the RCFE/Assisted Living portion of the campus, based on the information obtained, the above allegations are deemed Unfounded. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Administrator advised, and a copy of this report issued. *due to technical issues, see hard copy for facility representative's signature Unfoundedthe state’s words, verbatim · CDSS document, Apr 4, 2024 · control 31-AS-20240328102957