Complete Harmony Board and Care

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management-deficiencies visit at the facility at 09:45 AM. LPA met with facility staff who contacted the facility Administrator Nuritsa Martinyan. The Administrator arrived to the facility at 10:10 AM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, reviewed one (1) resident file, and interviewed two (2) residents, two (2) staff members, and the Administrator between approximately 10:12 AM and 12:00 PM. During the physical plant tour LPA observed the under-sink storage in bathroom #1 to be unlocked. LPA observed this storage to contain laundry chemicals, bleach, floor cleaner and resident hygiene supplies. LPA notified the Administrator who immediately secured the items. The Administrator stated that the storage was left unlocked by Staff #1 (S1) because S1 was doing laundry and had gotten distracted when LPA arrived to the facility. LPA informed the Administrator that between 09:45 AM and 10:10 AM LPA did not observe S1 doing laundry and that disinfectants, cleaning solutions, and other similar items which could pose a danger to residents must remain in locked storage and may not be left unattended. LPA informed the Administrator that they were recently cited for a violation of California Code of Regulations (CCR) 87309(a) on 01/05/2026. LPA informed the Administrator that because this is a repeat violation of the same licensing regulation within a twelve (12) month period a civil penalty in the amount of $250 is being assessed on today’s date (07/16/2026). Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty was assessed (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 17, 2026

(a)... licensee shall ensure that disinfectants, cleaning solution...are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as a under sink cabinet which contained laundry chemicals, bleach, floor cleaner and resident hygiene supplies was left unsecured which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Administrator agreed to conduct an in-service training with all facility staff covering the importance of securing items listed in CCR 87309(a) and the facility's policies and procedures regarding securing dangerous items. Administrator agreed to submit proof of the completed training to CCLD no later... than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:15 AM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 10:39 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:40 AM the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are four (4) bedrooms in the facility; two (2) are single occupancy resident rooms and two (2) are dual occupancy resident rooms. LPA and the Administrator toured all four (4) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #1 and #2 contained direct exits to the outdoors of the facility. All direct exits were observed to contain functioning auditory alarms. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom, and one (1) is designated as a shared/common resident bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed near resident toilets and were properly secured. The water temperature was measured to be between 113.2 and 113.4 degrees Fahrenheit, which is in compliance with regulation. Continued on LIC 809C. COMMON AREAS: This included the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained activities for resident use and a fireplace. The fireplace was appropriately screened and contained no tools. The hallway was observed to contain storage closets which contained extra care supplies, and emergency food and water supplies. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms, along with the fire door, were tested at 11:19 AM and were functional at the time of the visit. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured lock box which contained knives and other sharp objects. Additionally, the kitchen contained a locked under-sink cabinet that contained soaps and cleaning chemicals as well as a locked cabinet that contained medications. LPA observed a fire extinguisher mounted on the wall to be purchased on 11/06/2024. LPA informed the Administrator that this was more than twelve (12) months from the inspection date. The Administrator had a new fire extinguisher purchased and installed at the time of the visit. OUTDOOR SPACE: The facility had one (1) emergency exit gate located in the front of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. The backyard was observed to contain a secured shed which contained care supplies and gardening supplies. LPA observed an unsecured saw blade and motor oil in the back yard of the facility. LPA informed the Administrator who secured the items at the time of the visit. RECORD REVIEW: Record review began at 11:27 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. All staff files contained all required documents and trainings. Two (2) resident files were reviewed. Both resident files had admission agreements that were printed on two sides of the paper. LPA informed the Administrator that the print in the agreement shall appear on one side of the paper only. One (1) admission agreement was observed to be missing the rate for all basic services which the facility is required to provide. Continued on LIC 809C. RECORD REVIEW CONT: Both resident files were observed to contain incomplete appraisal needs and services plans which were missing signatures. Both resident files were observed to be missing signed copies of the resident’s personal rights. Resident #1 (R1)’s bed was observed to contain full bed rails. LPA reviewed R1’s file and did not observe R1 to be enrolled with a hospice company. LPA informed the Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Administrator removed the full bed rails from R1’s bed at the time of the visit. MEDICATION REVIEW: Medication review began at 12:50 PM. Medications for two (2) of two (2) residents were observed. R1’s medication count did not correspond with the start date listed on their centrally stored medication and destruction record (CSMDR). LPA informed the Administrator who stated that R1 came with multiple packets of their medications. LPA reviewed R1’s CSMDR and did not observe any additional packages of medications listed. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted in October 2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident had no concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 5, 2026

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a post-licensing visit at 10:07 AM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 10:52 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:10 AM the LPA, along with staff #1 (S1) toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured lock box to contain knives and other sharp objects. LPA observed a fire extinguisher mounted on the wall to be purchased on 11/06/2024. The kitchen contained a locked under-sink cabinet that soaps and cleaning chemicals as well as a locked cabinet that contained medications. Continued on LIC 809C. COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains activities for resident use and a fireplace, it is appropriately screened and contains no tools. The hallway was observed to contain a storage closet which contained extra care supplies. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:42 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS: There are four (4) bedrooms in the facility; two (2) are single occupancy resident rooms and two (2) are dual occupancy resident rooms. LPA and S1 toured all four (4) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #1 and #2 contain direct exits to the outdoors of the facility. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom, and one (1) is designated as a shared/common resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed near resident toilets and were properly secured. The water temperature was measured to be between 113.5 and 116.6 degrees Fahrenheit, which is in compliance with regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. RECORD REVIEW: Record review began at 10:57 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Two (2) staff files were reviewed. All staff files contained all required documents and trainings. Two (2) current resident files and three (3) former resident files were reviewed. The two (2) current resident files contained all required documentation and signatures. No deficiencies were observed during file review. Continued on LIC 809C. MEDICATION REVIEW: Medication review began at 12:50 PM. Medications for two (2) of two (2) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/15/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident had no concerns with the facility. LPA interviewed one (1) staff member and the facility’s Administrator. The staff member was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During the interview S1 informed LPA that the facility recently had three (3) residents pass away in April. LPA reviewed the facility E-file and did not observe death reports submitted for the three residents. LPA reviewed the deceased residents’ files and observed the dates they passed away to be 04/18/2025, 04/23/2025, and 04/24/2025. LPA interviewed the Administrator and asked why no death reports were submitted to Community Care Licensing Division (CCLD). The Administrator stated that they had attempted to fax the documents multiple times. LPA informed the Administrator that during the visit between 11:14 AM and 11:51 AM they received the three faxed death reports. The Administrator was unable to provide LPA with proof of the death reports being faxed prior to today's insection (05/01/2025). LPA informed the Administrator that all incident and death reports must be submitted to CCLD no later than seven (7) days following the event. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. The Administrator had to leave the facility during the visit but has designated S1 to sign this report on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, May 1, 2025

Allegation investigated: Facility did not provide adequate care and supervision to a resident

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 02:22 PM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 02:28 PM. Entrance interview conducted and the reason for the visit was explained. During the initial complaint visit on 03/07/2025 LPA conducted a physical plant tour ,conducted a file review for five (5) residents, conducted a medication review for one (1) resident, interviewed the Administrator, one (1) staff member, and four (4) residents between 09:56 AM and 12:20 PM. During today’s visit between 02:25 PM and 03:15 PM LPA conducted a brief physical plant tour and interviewed one (1) staff member. Continued on LIC-9099C Substantiated The allegation of “Facility did not provide adequate care and supervision to a resident” alleges that the facility did not provide an adequate level of supervision for resident #1 (R1) which resulted in the elopement of R1 from the facility. LPA Byrne interviewed the Administrator who informed LPA that R1 eloped from the facility’s grounds on 03/01/2025. The Administrator stated that R1 left the facility when Staff #1 (S1) was busy assisting with the care of another resident of the facility. The Administrator stated that after it was observed that R1 had left the facility, they and other facility staff searched the areas around the facility for R1. LPA confirmed with the Administrator that R1 was found by the local police department and has been placed in the hospital awaiting discharge. LPA interviewed S1 who was working at the time of R1’s elopement from the facility. S1 stated that R1 eloped during breakfast time. S1 stated that R1 left from the front door of the facility while they were assisting another resident. S1 stated that they turned the front door’s auditory alarm off in the morning, but they had the front door closed. During the physical plant tour LPA observed the front door of the facility to be equipped with a functioning auditory alarm. However, the alarm was observed to be switched off due to the front door being propped open. Based on the information obtained during interviews and physical plant tour there is sufficient evidence to support the allegation of “Facility did not provide adequate care and supervision to a resident.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 29-AS-20250304101019

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 26, 2025

87464 Basic Services (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 interview the licensee did not comply with the section cited above as R1 eloped from the facility without staff's knowledge which poses a potential safety rick to clients in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Licensee will submit their plan on how they will ensure adequate staff supervision of clients to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to conduct an unannounced Case Management visit at the facility at 02:22 PM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 02:28 PM. Entrance interview conducted and the reason for the visit was explained. During an investigation into a complaint against the facility LPA interviewed the facility Administrator. The Administrator stated that upon admitting resident #1 (R1) to the facility they did not perform a pre-admission appraisal on the resident. LPA informed the Administrator of the importance of conducting pre-admission appraisals on residents. The Administrator expressed understanding and confirmed that they will conduct pre-admission appraisals on all future residents. During the physical plant tour LPA observed the facility's front door to be equipped with an auditory alarm. LPA observed the alarm to be switched off. During an interview with staff #1 (S1) they revealed that on 03/01/2025 a resident eloped from the facility. S1 stated that they turned off the alarm in the morning and did not hear R1 leave the facility. LPA informed the Administrator of the importance of auditory alarms being functional and active. The Administrator expressed understanding and confirmed that auditory alarms would remain active. The following deficiencies were cited (refer to LIC 809D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Mar 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Mar 26, 2025

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed... This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as the Administrator admitted that a pre-admission appraisal was not completed for R1 which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Licensee will submit a statement confirming that they understand the importance of conducting pre-admission appraisals and stating that they will not admit future residents without conducting a pre-admission appraisal. Licensee will submit proof of corrections no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(d) · Plan of correction due date: Mar 26, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as the front door auditory alarm was turned off and not activated during inspection and on 03/01/2025 which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Licensee will submit their plan on how they will ensure auditory alarms remain on and active at all times. Licensee will install an auditory alarm on the exterior gate to the facility. Licensee will submit proof of corrections to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced Case Management- Deficiencies inspection at 09:59 AM. During today’s visit LPA conducted a physical plant tour, conducted a file review for five (5) residents, conducted a medication review for one (1) resident, interviewed the facility Administrator, one (1) staff member, and four (4) of five (5) residents. Two (2) residents interviewed stated that they believe they are not getting the care they need at the facility. One (1) resident interviewed, Resident #1 (R1) stated that Staff #1 (S1) is unable to communicate in English and this causes discrepancies in the food they are served due to their dietary restrictions and in the administration of their medications. R1 stated that they had previously requested a copy of their Medication Administration Record (MAR) from the facility to verify the accuracy of the medications they are given and facility staff failed to provide the document. R1 stated that they have requested the facility to move them from their current room due to disagreements with their roommate and the facility has refused to move them. R1 stated that there are no activities offered at the facility and their health has declined as a result of the lack of physical activities. The facility Administrator and staff #2 (S2) stated that S1 utilizes Google translate to communicate with residents and understands English well. S2 and the Administrator stated that facility staff observe dietary restrictions of residents and administer medications as prescribed. The Administrator and S2 were unsure if staff failed to provide R1 with a copy of their MAR. The Administrator stated that at the moment the facility has no open beds to move R1 to but stated that they would move R1 from their room when a bed becomes available. The Administrator agreed to interview residents and incorporate activities that interest the facility’s residents. Continued on LIC 809C. During the file review LPA observed R1’s resident #3's (R3) file to be missing from the facility. During medication review LPA observed R1’s MAR to not be filled out and no record of medication’s administrations were logged. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(5) · Plan of correction due date: Mar 21, 2025

87468.2 Additional Personal Rights... (a) ...residents shall have all of the following personal rights: (5) To be served food...necessary to meet their nutritional needs. This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as one resident stated that they have been fed food which they are allergic to which poses a potential health risk to clients in carethe state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Licensee will submit their plan on how they will meet the identified resident's dietary needs and a statement of understanding confirming that they understand the importance of following resident's dietary restrictions to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a)(7) · Plan of correction due date: Mar 21, 2025

87468.2 Additional Personal Rights... (a) In addition...shall have..the... rights: (7) ...The licensee shall provide necessary information and support to ensure that residents direct the planning of their care... This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as one resident stated that they were not provided with access to their MAR to know what medications they were taking which poses a potential personal rights risk to clients in carethe state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: The licensee will submit a statement of understanding confirming that they understand the importance of including residents in the planning of their care needs and providing residents the nessicary information to plan their care needs to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Mar 21, 2025

87465 Incidental Medical and Dental... (a) ... by compliance with the following: (6) ... a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as one resident's MAR was observed to not be filled out and missing administrations of medications which poses a potential health risk to clients in carethe state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Licensee will submit their plan on how they will ensure resident's MARs are complete and accurately filled out to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Mar 21, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as two resident's file was observed to be missing from the facility which poses a potential personal rights risk to clients in carethe state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Licensee will submit a completed resident files for R1 and R3 no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Mar 21, 2025

87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities.... This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as residents stated that activities are not offered at the facility which poses a potential personal rights risk to clients in carethe state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: The licensee will submit their plan on how they will incorporate activities residents are interested in to CCLD no later than POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Trevor Byrne conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Nurista Martinyan. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At 09:59 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) non-ambulatory residents one (1) of which may be bedridden. The facility has two (2) private resident bedrooms, Rooms three (3) and four (4) and two (2) shared rooms, rooms one (1) and two (2). Rooms #1 and #2 have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no staff bedroom, awake night staff only is required. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) shared resident bathroom in the hallway and one (1) private resident bathroom attached to room #2. The resident bathrooms have a shower with non-skid materials. The toilet and showers have grab bars. The hot water temperature was tested in the bathrooms and was found to be within the range of 105*F and 120*F. Resident and staff records are stored in a locked cabinet which is currently located in the living room. Medications are centrally stored in a locked cabinet in the living room. The first aid supplies were complete, including a current version of the first aid manual. They were stored in the infection control station at the front entrance to the facility. Continued on LIC 809C. Kitchen knives are stored in a locked box in a kitchen cabinet. Stove burners are rendered inaccessible to the residents by the installation of child-proofing devices. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides poisons, or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in locked cabinets located in the kitchen and the hallway bathroom. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is appropriately screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is not hard wired. The smoke detector and carbon monoxide detectors were tested at 10:21 AM and functioned properly during the time of visit. There is one (1) fire extinguisher throughout the house. It was fully charged and did not exceed the expiration date. Hot water was tested in each bathroom, which included the resident bathrooms; and, the hot water ranged from 116.4 to 113.9 degrees Fahrenheit. The laundry area is located in the hallway bathroom. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a locked cabinet under the bathroom sink. Extra incontinence supplies are stored in the hallway closet. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility in all resident rooms. Continued on LIC 809C. The emergency telephone numbers, and other required postings are posted in the entryway to the facility. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by gates on either side of the home. There is a door gate with a self-latching mechanism for persons to enter the front yard. There are two (2) locked storage sheds in the back yard. One (1) shed belongs to the facility and contains extra wheelchairs, and bed supplies. There are not any bodies of water on the premises at the present time. At 10:36 AM LPA Byrne observed an unsecured hand saw located on the bottom shelf of a grill in the backyard of the facility. The Applicant immediately secured the saw. COMP III orientation was completed with the applicant during this pre-licensing inspection. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.the state’s words, verbatim · CDSS document, Jan 8, 2025

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 6 Census (if any clients in care): Unknown COMP II Participants: NURITSA MARTINYAN Interview Method: Telephone interview On December 12, 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 the understanding of the California Code Title 22 Regulations. 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. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 12, 2024