Beloved Living

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Cava conducted an unannounced case management visit to provide updated information regarding an immediate exclusion. LPA met with the administrator, Anush Badalyan, and explained the reason for the visit. On 7/3/26 LPA Reed conducted a case management visit and delivered two immediate exclusions for two staff – Staff#1(S1) and Staff #2(S2). During the course of the investigation and further review, it was discovered that S2 was not working at the facility at the time of the incident which could have happened on or before February of 2026. At which time S2 was not working at the facility. Therefore, the department has rescinded the immediate exclusion for S2. No further action required at this time. No deficiencies noted during this visit. Exit interview conducted with with the administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Case Management - Legal/Non-compliance

At approximately 1:45 p.m. on 07/03/26, Licensing Program Analyst (LPA) Nicholas Reed conducted a case management visit to deliver Immediate Exclusion letters. LPA met with Staff #1 (S1) and explained the purpose of the visit. The purpose of this visit is to deliver Immediate Exclusion letters for S1 and Staff #2 (S2). During a complaint investigation it was found that S1 had spoken inappropriately to a resident in care and S2 was present and did not report the incident to the proper agencies as a mandated reporter. The complaint was substantiated under Personal Rights 87468.1(a)(3). Deficiency is being noted on the corresponding LIC809-D page per Title 22 Regulations to address S2 not reporting the observation of verbal abuse towards the resident to the proper agencies as a mandated reporter. The Immediate Exclusion letters were hand delivered to S1 and the licensee. A copy of the Immediate Exclusion was hand delivered to S1 during today’s visit. S2 was not present at the time of the visit. Therefore, a copy of the Immediate Exclusion letter was not hand delivered to S2 and will be sent via mail/certified mail. No immediate health or safety issues observed. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jul 13, 2026

87211 Reporting Requirements: (c) … Any mandated reporter who... has observed or has knowledge of an incident … including an act or omission… shall report… immediately or as soon as practicably possible… This requirement was not met as evidenced by: Based on observation and review of evidence S2 was present during incident in which S1 is observed verbally abusing a resident in care and did not report the incident to the proper agencies which poses an immediate risk to the persons in care.the state’s words, verbatim · CDSS document, Jul 3, 2026

Plan of correction: Licensee will provide training to staff regarding Mandated Reporter and will submit a copy of sign-in sheet with duration of training and topic, training material by POC due date: 7/4/26.

Allegation investigated: Staff spoke to the residents inappropriately.

Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Nadia Shahbazian conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the facility staff, Tyler Grant and explained the reason for the visit. Licensee Anush Badalayan arrived at 9:30 AM and administrator Vahe Mkrchyan arrived at 10:30 AM, both were explained the reason for the visit. LPAs took a tour of the physical plant at 9:10 AM. LPAs reviewed facility staff roster (LIC 500), resident roster (LIC 9020), physician report, admission agreement, personal rights training for staff #3 (S3) was received on 12.6.2024 and personal rights training for staff #2 (S2) on 3.6.2026, and other documents pertaining to the investigation. Between 9:12 AM to 10:45 AM, LPAs interview facility staff and three (3) residents. Allegation: Staff spoke to the residents inappropriately. Continue to LIC9099-C Substantiated It was alleged that staff spoke to the residents inappropriately. LPAs interviewed facility staff and revealed that they would never speak to the residents inappropriately. LPAs interview with residents revealed that they are happy living at the facility and staff treat them with respect and dignity. During the course of the investigation LPA Ngo-Castaneda received video evidence which shows staff #3 (S3) observing resident #1(R1) in the floor and saying “Shut-up!” more than once. Based on LPAs observations, interviews which were conducted, and record review(s), there is sufficient evidence to substantiate. Therefore, the allegation is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview was conducted with licensee a copy of this report, LIC 9099-D, and appeal rights were Allegation: Staff hits residents. It is alleged that staff hit residents in care. LPAs interview with facility staff revealed that they do not hit the residents. LPAs interviews with residents revealed that they are happy and safe at the facility. Residents have not experience or witness staff hitting them. Upon review of facility records there was no information to support the allegation. LPAs observed residents in care well with out visible bruises. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit Interview conducted, and a copy of this report was given to the licensee.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 31-AS-20260622145838

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 1, 2026

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature,… This requirement is not met as evidence by: Based on interviews and record review conducted licensee did not ensure S3 treats residents in care with dignity and respect which poses an immediate safety, health, and personal rights to the persons in care.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: Licensee will provide in-service training to all staff regarding resident’s personal rights, de-escalation of behaviors, and will provide a copy to the department of training material, sign in sheet with time, date, and duration of training, and will certify in writing that will ensure the health and safety of each resident in care by POC due date: 7/1/26.

Type of visit: Case Management - Deficiencies

On 6.22.2026 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced case management visit and met with staff, Tyler Grant, and was explained the reason of the visit. At 9:22 AM, Anush Badalyan, who is the licensee arrived and was explained the reason for the visit. During the course of the investigation, it was determined that Resident #1 (R1) was found unresponsive on the floor on 6.18.2026. Interview with licensee (S1), revealed that S2 found R1 unresponsive on the floor at 9:30 AM and called staff #2 (S2) for assistance to lift R1 to the bed and was unsuccessful. S2 called S1 regarding the situation of R1. S1 then arrive to the facility 30 minutes later at 10:00 AM and then 9-1-1 was called. Record review revealed that R1 has a Do Not Resuscitate (DNR) on file. During LAFD visit on 6.18.2026 and LPA today's visit, S1 failed to provide hospice records. Deficiency will be cited in LIC 809-D. Interview with S1 revealed that facility administrator is dismissed as of 6.22.2026 at 9:06 AM. S1 has 10-days to send all the required documents to LPA. Deficiency will be cited in LIC 421 FC for repeat violation from 5.12.2026. LPA observed expired medication, residents name on prescription is removed, and facility keeping residents medication who are no longer reside at the facility were kept. Exit interview conducted, citation issued, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(C)(1) · Plan of correction due date: Jul 6, 2026

(1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers. This requirement was not met as evidenced by information received from LAFD and staff.the state’s words, verbatim · CDSS document, Jun 22, 2026

Plan of correction: As POC, the licensee and staff shall obtain training to address this section of the regulation. As proof training was received, a copy of the training log addressing this section will be submitted to the licensing agency by 6.23.2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(i) · Plan of correction due date: Jul 6, 2026

Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 medications were kept when resident passed or move out, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 22, 2026

Plan of correction: Licensee will dispose residents medications who are not at the facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA was met with Tyler Grant who is the staff and was explained for the reason of the visit. At 9:35 AM Anush Badalayan who is the Licensee met with LPA, explained the reason for the visit. At 9:37 AM, with the assistance of Licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 12:06 PM smoke alarms were tested and were operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 3/26/2025. During the visit the facility is at 71 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 1 bedridden; hospice waiver for 6. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the cabinet under the sink and laundry room. Continue to LIC 809-C Bedrooms: There were five (5) bedrooms designated for residents' and staff use. Bedroom #1 and bedroom #2 are for private used. Bedroom #3 and bedroom #4 is shared. Bedroom #4 has only one (1) resident. The bedrooms that are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #5 is for staff is locked and inaccessible to residents. Bathrooms: There are two (2) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 106.3 degrees Fahrenheit for bathroom #1 located inside bedroom #2. Bathroom #2 is across bedroom #4. Hot water temperature was measured at 105.9 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. Fire place is close, block-off, and non-operational. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage detached and is used for storage. Laundry service: Laundry is beside the kitchen. There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the kitchen under the sink and laundry room. Continue to LIC 809-C Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the dining table. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, and HIV/AIDS and TB training. S3 has been working at the facility since March of 2026, fingerprint clearance and association to facility is missing, immediate civil penalty will be issued. Facility is missing liability insurance, licensee showed LPA an expired insurance. Deficiency will be cited in LIC 809-D. Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the CSMDR. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. LPA observe residents medications who has pass away or move, medications are kept and some medications has their name scratch off. Deficiency will be cited in LIC 809-D. Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current records only for some residents. One (1) out of four (3) residents, R2 is missing pre-admission appraisal (LIC 603) and admission agreement who has been at the facility since 5.1.2026, deficiencies will be cited in LIC 809-D. R2 does not have an inventory of personal belongings, technical violation will be issued. Planned activities are offered. Deficiencies were cited in LIC 809-D, facility is not within CA code of Regulations Title 22 or Health and Safety Code Exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, May 12, 2026

Allegation investigated: Administrator is not on premises a sufficient amount of hours to manage facility.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced initial visit for the above allegation. LPA met with CEO, Anush Badalyan (S1), and explained the reason for the visit. Entrance interview conducted. . LPA took a tour of the physical plant. At 12:00 PM, LPA interviewed the CEO (S1) and staff #2 (S2). At 12:07 PM, LPA interviewed a total of four (4) residents. At 1:00 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 (staff roster), resident roster (LIC 9020), intake sheet, hospice records and other pertinent documents. Interview with W1 at 12:25PM. LPA interviewed two (2) staff, four (4) residents, and one (1) witness from 12:07-12:30PM. Continue to LIC 9099-C Substantiated Allegation #1: Administrator is not on premises a sufficient amount of hours to manage facility It was alleged that the facility administrator is not on premises a sufficient amount of hours to manage facility. Interview with staff revealed that facility administrator is a nurse practitioner (NP) and that ‘their [NP] is really busy seeing patients outside.’ and usually spends their time here at the facility to conduct tours with potential residents. If facility residents have an emergency, the two (2) staff will provide assistance with emergency. Interview with residents and staff revealed that facility’s administrator rarely and never comes to the facility, they do not know how the facility’s administrator looks like. Record Review revealed that S1 does not have LIC 308 to be the facility responsibility designee. Per LIC 500 administrator is listed to be at the facility between Monday to Friday from 10:00AM to 2:00PM. Facility does not follow LIC 500 schedule. Based on interviews there is sufficient information to verify validity of the complaint. Therefore, the allegation is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Health and safety issues were noted at the time of this visit address in a case management visit. An exit interview was conducted, and a copy of this report, LIC 9099-D, and appeal rights were provided. It is alleged that the facility does not provide adequate supervision to residents in care. R3 sustained facial scratches from R1. S2 was at the adjacent room and redirected R1 immediately to another activity. Record review revealed that R1 is on hospice, R2 is on Home Health, R3 is non-ambulatory, and R4 is bedbound. Interview with residents revealed that R1 can be aggressive and disruptive towards other residents’. Interview with W1 revealed that R1 can get aggressive that needs more staff supervision. Based on interviews and record review, there is insufficient information to verify validity of the complaint. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted, copy of this report give to CEO (S1).the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 31-AS-20260213125854

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87495(a) · Plan of correction due date: Mar 9, 2026

Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit ...This requirement was not met as evidenced by: facility administrator is never at the facility, residents and staff is not even aware what they look like.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The facility administrator will provide an updated LIC 500 with corrected time for administrator, LIC 308, and a written certification that administrator will be at the facility a sufficient amount of hours and available for emergencies to the department by POC due date.

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 related to the complaint # 31-AS-20260213125854. On 2.23.2026 while LPA was conducting complaint investigation, LPA discovered the following: Staff #1 (S1) is the appointed designee when facility administrator is not available. Record review revealed S1 does not have LIC 308 form. It was also revealed that S2 sleeps at the facility and that S2 would work off the clock during grave yard shift when residents needed help. Resident #3 (R3) sustained scratched on their face and facility did not report incident to RO. Resident #1 (R1) does not have Appraisal Needs and Service Plan (LIC 625). Under Title 22 Regulations, the following citation is issued and recorded on LIC809-D. 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, Feb 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 9, 2026

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 as evidenced by: Based on interviews the facility does not have adequate staff to care for residents. This pose a potential health & safety risk to the residents in care. S2 would be working off the clock (24/7).the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Administrator will email LPA LIC500 showing adequate staff coverage by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Mar 9, 2026

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date... This requirement was not met as evidenced by: Based on record review R3 sustanined scratched on their face from R1. Facility staff did not report to RO about the incident. This pose a potential health & safety risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Facility staff will send incident report to RO before POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(1)(a) · Plan of correction due date: Mar 9, 2026

(a) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factor. This requirement was not met as evidenced by: Based on record review the facility does not have R1 appraisal needs and service plan (LIC 625), R1 was admitted to the facility on 1.27.2026. This pose a potential health & safety risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Facility staff will send R1 LIC 625 to LPA by the due the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.618(a) · Plan of correction due date: Mar 9, 2026

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement was not met as evidenced by: Based on record review the facility does not have S1 does have LIC 308.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: S1 will fill-up LIC 308 and email LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA was met with Tyler Grant who is the staff and was explained for the reason of the visit. At 12:35 PM Anush Badalayan who is the Licensee met with LPA, explained the reason for the visit. At 12:49 PM, with the assistance of Licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 2:17PM smoke alarms were tested and were operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 3/26/2025. During the visit the facility is at 71 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 1 bedridden; hospice waiver for 6. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the cabinet under the sink and laundry room. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedroom #1 and bedroom #2 are for private used. Bedroom #2 is vacant. Bedroom #3 and bedroom #4 is shared.. The bedrooms that are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #5 is for staff is locked and inaccessible to residents. Continue to LIC 809-C Bathrooms: There are two (2) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 117.8 degrees Fahrenheit for bathroom #1 located inside bedroom #2. Bathroom #2 is across bedroom #4. Hot water temperature was measured at 118.9 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. Fire place is close, block-off, and non-operational. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage detached and is used for storage. Laundry service: Laundry is beside the kitchen. There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the kitchen under the sink and laundry room. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the dining table. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, and HIV/AIDS and TB training. Continue to LIC 809-C Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the CSMDR. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current records only for some residents. Two (2) out of four (4) residents, residents #2 (R2) and residents #4 (R4), are missing physicians report. Deficiencies will be cited in LIC 809-D. Planned activities are offered. Deficiencies were cited in LIC 809-D, facility is not within CA code of Regulations Title 22 or Health and Safety Code Exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, Apr 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Liezl De La Cerra conducted an annual required visit and inspection of the facility. LPAs was met with Danil Stukov who is the staff and was explained for the reason of the visit. At 3:00 PM Anush Badalayan who is the Licensee met with LPA, explained the reason for the visit. At 3:24 PM, with the assistance of Licensee, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 3/28/2024. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 1 bedridden; hospice waiver for 6. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked in the drawer. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the cabinet under the sink and laundry room. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1 and bedroom #2 are for private used. Bedroom #3 is shared; bedroom #4 is vacant. The bedrooms that are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #5 is for staff. Continue to LIC 809-C Bathrooms: There are two (2) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 116 degrees Fahrenheit for bathroom #1 located inside bedroom #2. Bathroom #1 needs to have the toilet cleaned and changed the non-skid mat. Deficiency will be cited on LIC 809-D. Bathroom #2 is across bedroom #4. Hot water temperature was measured at 117.2 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway. Common Areas: LPAs toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPAs observed common areas to be very clean and tidy. Fire place is close, block-off, and non-operational. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage detached and is used for storage. Laundry service: Laundry is beside the kitchen. There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the kitchen under the sink and laundry room. Staff Files: LPAs also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the dining table. Records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, and HIV/AIDS and TB training. Facility has missing fingerprint clearance for one (1) out of four (4) staff review. Civil penalty will be issued. Continue to LIC 809-C Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged. Medication was not lock when LPA arrived. Deficiency will be cited on LIC 809- D. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current records only for some residents. Two (2) out of four (4) residents are missing physicians report, appraisals, functional capability, TB test, and diagnoses. Deficiencies will be issued on LIC 809-D. Planned activities are offered. Facility is within CA code of Regulations Title 22 or Health and Safety Code. Deficiencies were found, this will on LIC 809-D, exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, Mar 28, 2024

The state marks this report as 14 pages; the online copy we transcribed has 13. You can request the full file from the county licensing office.