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Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff, Karine Khachatryan, and explained the reason for the visit. Approximately, around 10:30 AM administrator, Marine Stepanyan, arrived and was explained for the reason of the visit. At 12:19 PM, with the assistance of of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 11:32 AM smoke alarms were tested and are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is beside the living room. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for six (06) residents six (6) non-ambulatory resident, of which one (1) maybe bedridden, cleared for bedroom #3. 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 drawer in the kitchen. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1 and bedroom #2 is private. Bedroom #3 and bedroom #4 are shared and is used for residents only, Bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C Bathrooms: The facility has two bathrooms. Bathroom #1 is located by the hallway in beside bedroom #1. Hot water measured at 118.5 degrees Fahrenheit. Bathroom #2 is located inside bedroom #3. Hot water measured at 119.0 degrees Fahrenheit. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Residents dining table fits enough for six (6). Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the laundry room. Cleaning supplies are being stored in an locked cabinet in the laundry room. The facility does not have a swimming pool or body of water. Office space is in the entrance area beside the entrance of the facility. Properly labeled medications were locked in the kitchen cabinets. The facility does not have a garage only car ports. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. 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. Medications: Medication and Medication Records (MMR) were review for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda met with facility licensee Adrine Akopyan for a Plan Of Correction (POC) visit. The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 2.12.2025 Entrance interview conducted. At 9:35 AM LPA toured the home and requested the following: -CCR 87465(a)(4) Incidental Medical and Dental Care Services: POC: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 medication bubble pack were randomly punch, that results in inconsistency, which poses/posed a potential health, safety or personal rights risk to persons in care. POC date 2.19.2025: Licensee agreed to do a vendor training for medication dispensing. - CCR 87457(c)(1)(a) Incidental Medical and Dental Care Services: POC: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 R3 LIC 301, appraisal and pre-placement is missing, which poses/posed a potential health, safety or personal rights risk to persons in care. POC date 2.24.2025: Licensee agreed to have R3 pre-placement filled and signed. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA was greeted with staff Seda Vardanyan and Yeghisabet Tonikyan and was advised for the reason of the visit. At 1:10 PM Adrine Akopyan who is the licensee met with LPA, explained the reason for the visit. At 2:07 PM, with the assistance of licensee, LPA 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 11/4/2024. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared maybe for six (06) non-ambulatory residents, one (1) bedridden. Hospice waiver for six (6); one maybe bedridden bedroom #3. 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 drawer in the kitchen. 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 kitchen below the sink. Office is located beside the living room. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1 is private. Bedroom #2, bedroom #3, and bedroom #4 are shared and is used for residents only, Bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C BATHROOMS: The facility has two bathrooms. Bathroom #1 is located by the hallway in beside bedroom #1. Hot water measured at 119.1 degrees Fahrenheit. Bathroom #2 is located inside bedroom #3. Hot water measured at 116.2 degrees Fahrenheit. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. 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. 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 bodies of water. There is no garage only car port. Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located inside bathroom #1. 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 is located inside the kitchen. 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, administrator certificate, 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 medications log with proper documentation from the clients’ doctor. Improper dispense of medication was seen on residents bubble pack. Deficiency will be cited in LIC 809-D. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisal. Planned activities are offered. R3 is missing ID, appraisal needs and service plan, and pre-placement. Deficiencies will be cited in LIC 809-D. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, Feb 12, 2025

Allegation investigated: Resident was pushed by staff.

On 11.4.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced complaint visit for the above allegation. LPA arrived at 9:30 a.m. and was greeted by staff, Seda Vardanyan, LPA explained the reason for the visit. At 9:45AM licensee, Adrine Akopyan arrive and was advised the reason for the visit. At 9:50AM LPA conducted a physical plant tour of the facility with the assistance of the licensee. From 10:00 a.m. to 12 NN, LPA Ngo-Castaneda interviewed licensee and one (1) staff familiar with the incident the complaint is about. At 11:30 AM - 12:30 PM LPA reviewed and obtained documents relevant to the investigation. Continue to LIC 9099-C Unsubstantiated Allegation: Resident was pushed by staff. In regards to the allegation, it was reported that a staff pushed resident #1 (R1), no specific staff was stated. To investigate the allegation LPA Ngo-Castaneda interviewed licensee, staff, emergency contacts in LIC 601, and residents regarding the incident in question. Interview with S2 regarding the incident revealed that R1 cellphone rang and S2 helped pick-up the call. S2 overheard that R1 told the caller that a staff 'push' R1. Interview with licensee and S2 revealed that the allegation is untrue. LPA interview two (2) out of two (2) residents, R2 and R3 revealed unanimously that they are happy and content living at the facility. Residents did not experience or witness being abused or pushed with staff in the facility. LPA also called emergency contact in LIC 601 and found that they are happy for R1 living in the facility and stated that the allegation is untrue. Therefore, there was not enough evidence to prove the alleged violation did or did not occur therefore the allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 31-AS-20241025111603

Type of visit: Case Management - Deficiencies

On 11.04.2024 in conjunction with an initial complaint visit control number 31-AS-20241025111603. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda completed an unannounced CASE MANAGEMENT- Deficiencies visit. LPA met with Licensee Adrine Akopyan, explained the purpose of the visit. During the facility tour at 9:50 AM . LPA observe the following: S2 medication was kept in an unlock room in bedroom #1 and bedroom #2. Chemicals were found to be kept in storage under the sink with beverages in the kitchen. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D). Copy of this report provided, appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Nov 5, 2024

Incidental medical and dental Care: The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees supervision of the centrally stored. This requirement is not met by S2 medication was seen in an unlock bedroom #1 and bedroom #2 that is accessible to the residents in the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2024

Plan of correction: Staff needs to lock and store their medication. POC was done during today with licensee. Medication was stored and lock away in the locked medicine cabinet.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(24) · Plan of correction due date: Nov 5, 2024

General Food Service Requirements: The following food service requirements shall apply: (24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement is not met by licensee where LPA saw cleaning supplies kept under the sink with beverages for consumption. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2024

Plan of correction: Staff should not store checmicals with food/ beverages in the same storage. POC was done during today with licensee. Chemicals were stored in a lock storage cabinet in the bathroom located in the hallway.

Type of visit: Prelicensing

At 9:30am Licensing Program Analysts (LPAs), Leslie Ngo-Castaneda and Perchui Milena Khurshudyan conducted an announced pre-Licensing visit to the above facility and met with Administrator, Ani Palezyan and Licensees Adrine Akopyan, Marine Stepanyan. Fire Clearance was approved on 10/26/2023 for a maximum capacity of six (6) residents, of which five (5) Non-Ambulatory and one (1) bedridden residents in room #3. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of team touring the physical plant inside and outside and observed the following: KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. At 9:50am, the team observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. FIRE EXTINGUISHER was last purchased on 2/27/2024 is located in the hallway nest to the kitchen. First-aid is complete and new. BEDROOMS: There are four (4) bedrooms designated for client use. All bedrooms are furnished with beds, dresser and required bedding and linen. Extra linen is available in each bedroom. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. Facility will have awake staff. Bedroom #1 is for private use located at the end of the hallway. Bedroom #2 is shared located at the center of the hallway. Bedroom #3 is shared and is located at the other end of the hallway. Bedroom #4 is located in between kitchen and living room. laundry. Continue to LIC 809-C BATHROOMS: At 10:00am the team observed two (2) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured between 119°F. observed appropriate grab bar and had non-skid mat. Bathroom #1 is located in the hallway beside bedroom #1. Bathroom #2 is located inside bedroom #3 for private use. Hot water for bathroom #2 measured at 119°F. COMMON AREAS: The facility maintains a comfortable temperature at 71°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Office is located by the entrance, by the living room. MEDICATION: The medications will be kept in the kitchen cabinet and the team observed the cabinet kept locked and inaccessible to residents in care. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:30am they were tested and observed to be operational. SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water. The driveway, passageway and entrance to the home was clear of obstructions. All entry and exit doors have a functional auditory alert when the doors open. NO GARAGE – there is only car port. In addition, LPAs observed laundry room is located in the separate room inside the bathroom 1. The washer/dryer appear to be in good condition. Laundry supplies are kept lock and inaccessible when not in use with supervision. Component III was conducted with the administrator and licensee. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved. Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Adrine Akopyan (Corporate Board Member) & Ani Palezyan (Administrator) Interview Method: Virtual interview via Microsoft Teams On January 04, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 4, 2024