Assisted Senior Care Facility

Type of visit: Required - 1 Year

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with the staff Anahit Niazyan and the Administrator Designee was contacted via telephone. LPA was informed that the Administrator is unable to come to the facility due to a sickness; however, the Administrator Designee will arrive shortly. LPA explained the reason for the visit. LPA and the Administrator Designee toured the facility inside and out. Kitchen: At 9:45 AM, LPA and Administrator Designee toured the kitchen and the kitchen is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in the kitchen drawer. MEDICATIONS: LPA observed the medication locked and inaccessible to residents in care in a cabinet in the dinning room. SAFETY: The smoke alarms and carbon monoxide detector are battery operated. The facility has a fire extinguishers that was purchased on 09/2/2025. One fire extinguisher is located on the kitchen wall. BEDROOMS: There are five (5) bedrooms designated for resident’s use. Bedroom # (3) is shared. All other four (4) bedrooms are private. Bedroom number one is cleared for bedridden. All other rooms are cleared for non-ambulatory. All bedrooms are furnished with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Continue on LIC 809C BATHROOMS: The facility has three (3) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 116.08 degrees. COMMON AREAS: These included the TV and activity room which were equipped with living room furniture, a television, tables and chairs. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards. LAUNDRY ROOM/Garage: The laundry room is located in the in the hall. All the cleaning supplies and detergents were observed locked in a storage area in bedroom # (3). The garage is used for extra food and PPE supplies. OFFICE/STAFF WORKSTATION: Staff workstation is located at the entrance of the facility. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and outdoor furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is only one emergency exit and LPA observed free of obstruction and hazard. The gate had a inward latch. Between 10:30 AM to 11:45 AM, LPA reviewed records of six (6) residents and two (2) staff. Residents and staff records appeared to be complete and updated Administrative: LPA collected Certificate of Liability Insurance, and LIC500. No deficiency issued during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 24, 2025

Type of visit: Case Management - Incident

At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management - Incident visit to this facility and met with staff and the Administrator Gayane Aghabekyan and Administrator Rima Agaronyan were contacted and arrived at the facility shortly after. LPA explained the reason for the visit. On 04/30/2025, Community Care Licensing Division (CCLD) received an incident report for Resident #1 (R1). It was reported that on 04/28/2025, R1 was noted to have a skin breakdown and the Administrator contacted R1's Primary Physician and R1 was assessed by Kaiser Home Health Registered Nurse(HHRN). The (HHRN) confirmed that R1 has stage 3 pressure ulcer near the buttocks area. During today's visit, LPA conducted an interview with R1 who informed LPA that two weeks prior to 04/28/2025, the staff #1, Hasmik Yeghiazaryan noticed redness on the buttocks area. R1 also informed LPA that the staff was repositioning R1 each four (4) to five (5) hours daily prior to 04/28/2025. Furthermore, LPA conducted an interview with the Administrator and Administrator Designee and both denied ever been notified from any of the staff that R1 had any redness prior to 04/28/2025. LPA conducted review of R1's facility file, Physician Report dated 04/1/2024, Preplacement Appraisal date on 03/09/2024, Appraisal Needs and Services Plan on 04/30/2025. Admission Agreement date on 03/9/2024. Review of Physician report revealed that R1 has history of skin condition or breakdown near buttock area and review of Appraisal Needs and Services Plan revealed that page #4 was completed partially, and page #5 was completed only; therefore, no proper assessment was conducted and R1 ended up having stage 3 pressure ulcer as of 04/28/2025. Although R1 currently is receiving wound care through Kaiser home health, the facility failed to submit an exception letter to CCLD in a timely manner. Therefore, deficiencies will be cited on LIC 809D. Appeal rights explained copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(a) · Plan of correction due date: May 5, 2025

87611(a) General Requirements for Allowable Health Conditions (a) Prior to accepting or retaining a resident with an allowable health condition as specified in Section 87618… Section 87631, Healing Wounds; licensees… shall obtain Department approval: This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above by not obtaining an approval from the department for R1's prohibited health condiction (stage 3 pressure wound) which was discovered on 04/28/25 this poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: The Aministrator will submit a written request for an exception for R1's restricted health condition (Pressure Wound Care) by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87615(a) · Plan of correction due date: May 5, 2025

87615(a) Prohibited Health Conditions (a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. Based on record review & interviews the licensee did not comply with the section cited by R1 developing stage 3 ulcers while under the facility care. This poses an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: The Administrator has agreed to the following: All staff take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name, date of schedule. Upon completion submit the training material and staff sign in sheet.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 9, 2025

Basic Service: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and record reviews the licensee failed to provide care and supervision to R1 who developed stage 3 ulcers residing at the facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(c)(2)(A-D) · Plan of correction due date: May 9, 2025

Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply by not making sure all trained staff followed the "in service" training knowledge and conducted daily body checks on R1 for the history of skin breakdown which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: The Administrator shall submit proof that all staff will complete "in service" trainings. The Administrator shall submit proof to LPA by POC due date. Additionally, submit a complete body check forms for each resident for the next two week.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: May 9, 2025

Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary....... the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical... This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above. Administrator completed partial reappraisals for R1 on 04/30/2025 upon observing the stage 3 ulcer on R1's buttocks area, which poses/posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Administrator agreed to submit a statement of understanding on how all residents will have a proper reappraisal when changes occur to ensure their needs are met. Additionally, the Administrator will properly complete the reappraisal for R1 and submit to LPA by POC date.

Type of visit: Required - 1 Year

At 01:00 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with the Administrator Designee Rima Agaronyan, and disclosed the reason for the visit. LPA and the Administrator Designee toured the facility inside and out. Kitchen: At 1:18 PM, LPA and Administrator Designee toured the kitchen and the kitchen is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in the kitchen drawer. MEDICATIONS: LPA observed the medication locked and inaccessible to residents in care in a cabinet in the dinning room; however, bedroom # (1) closet of a resident had two Ziplock bags filled with medications of one of the caregivers accessible to the resident in care. Additionally, LPA observed more medications in all residents bedrooms accessible to residents in care. SAFETY: The smoke alarms and carbon monoxide detector are battery operated. The facility has a fire extinguishers that was purchased on 09/07/2024. One fire extinguisher is located on the kitchen wall. BEDROOMS: There are five (5) bedrooms designated for resident’s use. Bedroom # (3) is shared. All other four (4) bedrooms are private. Bedroom number one is cleared for bedridden. All other rooms are cleared for non-ambulatory. All bedrooms are furnished with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. BATHROOMS: The facility has three (3) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 116.08 degrees. Continue on LIC 809C COMMON AREAS: These included the TV and activity room which were equipped with living room furniture, a television, tables and chairs. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards. LAUNDRY ROOM: The laundry room is located in the in the hall. All the cleaning supplies and detergents were observed locked in a storage area in bedroom # (3). OFFICE/STAFF WORKSTATION: Staff workstation is located at the entrance of the facility. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and outdoor furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is only one emergency exit and LPA observed free of obstruction and hazard. The gate had a inward latch. Between 3:00 PM to 4:00 PM, LPA reviewed records of three (3) residents and two (2) staff. Residents and staff records appeared to be complete and updated Administrative: LPA collected Certificate of Liability Insurance, and LIC500. A deficiency cited during today’s visit. Appeal Rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 28, 2024