Green Life Care Facility

Type of visit: Case Management - Other

At 11:00 am, Licensing Program Analyst (LPA) Huma Rahimi conducted a Case Management visit - CLOSURE and met with the Administrator designee. An entrance Interview was conducted. During the visit, LPA toured the facility and confirmed that there were no residents residing in the home and that operations had ceased. The Administrator designee stated that the closure was licensee-initiated due to no longer being interested in maintaining the license. The Administrator designee will submit the license to Community Care Licensing Division (CCLD) office on 08/21/2026. LPA will submit the file for closure upon returning to the Woodland Hills South Regional Office. The Administrator designee was informed not to admit/retain any residents at the home who require care and supervision. Exit Interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 19, 2026

Type of visit: Office

Licensing Program Manager (LPM) Nichelle Gillyard, LPM Mary Flores, and Licensing Program Analyst (LPA) Huma Rahimi met with Mineli Manukian, Florence Perigrino, and Arpa Adamian to conduct an informal office meeting held at the Woodland Hills South Adult and Senior Care Regional Office. The purpose of the meeting was to discuss the facility’s chronic non-compliance and issues related to operation of the above listed address. Green Life Care Facility Inc was licensed on 12/21/2023. Since licensure, the licensee has been cited for multiple deficiencies and assessed civil penalties that are of concern and require corrective action. On 01/16/2025, an annual inspection identified Type A deficiencies for criminal records and Type B deficiencies for personnel records, resident records, reporting requirements, and liability insurance. Civil penalty: $500. On 01/05/2026, an annual inspection identified Type A deficiencies including hot water maintenance/operation, storage/access, two criminal record deficiencies, postural supports, and incidental medical/dental care. Type B deficiencies included personnel records, resident records, medical assessments, reporting, blocked exits, personal accommodations, and staff CPR/first aid training/designation. Civil penalties: $1,000. On 01/16/2026, a Plan of Correction (POC) visit found repeated deficiencies in both Type A (criminal records, storage/access, incidental medical/dental care) and Type B (personnel records, resident records, medical assessments, reporting, blocked exits, staff training/designation). Civil penalty: $5,800 for uncorrected POCs. Continue on LIC 809C During the Department’s review of the facility’s ongoing non-compliance, it was discovered that the licensee’s corporation was dissolved effective 07/01/2025. As a result, the facility operated without an active corporate entity from 07/01/2025 through October 2025. Additionally, the Department determined that a change in ownership and control occurred in October 2025 and was not reported to the Community Care Licensing Division (CCLD) as required. From October 2025 to the present, the facility has continued to operate without a valid license under the direction and control of the operator, Florence Perigrino. During the informal meeting the operator submitted POCs for deficiencies issued on 01/05/2026. Upon review of the POCs, LPA will clear the POCs accordingly. Additionally, LPM requested POCs for the deficiencies issued on 01/16/2025, from the Licensee. Both the unreported operation and the corporation dissolution, resulting in the facility operating without a valid license, were addressed during the informal office meeting held on 01/23/2026. A Notice of Operation in Violation of Law (NOVL) will be issued. A deficiency was issued and appeal rights were explained. An exit interview was conducted, and a copy of this report was signed and delivered.the state’s words, verbatim · CDSS document, Jan 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.10 · Plan of correction due date: Feb 9, 2026

1569.10 RCFE; license or permit; necessity No person, firm, partnership, association, or corporation within the state.....without a current valid license or current valid special permit... This requirement is not met as evidenced by: Based on interviews conducted, LPA was informed that R1, R2, R3, were receiving elements of care and supervision, which posed an immediate health and safety risk or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: Operator will submit an application to CCL by the POC due date of 02/09/2026.

Type of visit: Case Management - Other

At 2:00 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management – Other visit. LPA met with the staff/Administrator, Florence Perigrino, and explained the reason for the visit. The purpose of the case management visit was to deliver a copy of the informal letter for a meeting scheduled on January 23, 2026, at 10:00 AM at the Woodland Hills Regional Office, located at 21731 Ventura Blvd, STE 250, Woodland Hills, CA 91364. During the visit, LPA was informed that in October 2025, the facility was sold to Ms. Perigrino. LPA conducted a document review and did not observe any documentation indicating that Community Care Licensing Division (CCLD) or LPA were made aware of this transaction. LPA was informed that a letter of notification will be submitted along with a new application for a license to CCLD. An exit interview was conducted. A copy of this report was signed and delivered..the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: POC

At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Plan of Correction (POC) visit at the facility. LPA met with Staff #1 (S1) and Staff #2 (S2). The Administrator was contacted via telephone and stated they were unable to come to the facility but designated staff to assist with the visit and accept the report. The purpose of the POC visit was to determine whether deficiencies cited during the Annual Inspection on January 5, 2026 were corrected. The following deficiencies are NOT CLEARED: 1. 87303(e)(2) – Hot Water Temperature - LPA tested the hot water temperature at resident-use faucets and observed the temperature to be 119.3°F, which does not exceed the maximum allowable temperature of 120°F. Plan of Correction met. 2. 87309(a) – Locked Storage of Hazardous Items- LPA observed knives, sharps, cleaning supplies, tools, and poisonous substances stored unlocked in kitchen cabinets and the laundry room, accessible to residents in care. Plan of Correction not met. 3. 87355(e) & 87355(e)(3) – Criminal Record Clearance and Association- LPA reviewed LIS and Guardian and did not observe Staff #1 (S1) associated with the facility, nor Staff #2 (S2) fingerprint cleared and associated prior to working. Plan of Correction not met. Continue on LIC 809C 4. 87307(d)(6) – Obstructed Exits - LPA observed emergency exits obstructed by a stool, trash can, and laundry basket in Bedroom #3. LPA confirmed that the dog previously obstructing the emergency exit through the activity room is in the process of being removed; however, during today’s inspection, the Bedroom #3 emergency exit remained obstructed by a stool, a trash can, and a laundry basket. Emergency exits were not maintained free of obstruction as required. Plan of Correction not met. 5. Health and Safety Code §1569.618(c)(3) – CPR and First Aid Coverage - Facility did not ensure that at least one staff member with current CPR and First Aid certification was on duty and on the premises at all times. Plan of Correction not met. 6. Health and Safety Code §1569.618(a) – Administrator Presence- Administrator was not present at the facility during normal working hours, and no documentation was provided identifying a designated facility manager responsible for operation during the Administrator’s absence. Plan of Correction not met. 7. 87412(f) & 87412(g) – Personnel Records - LPA requested personnel records; however, complete records were not available for review and were not maintained at the facility. No staff training records were provided. Plan of Correction not met. 8. 87506(a) – Resident Records- LPA reviewed resident files and observed incomplete records. Resident files for R2 and R3 lacked required documentation beyond admission agreements. Plan of Correction not met. 9. 87458(c)(1)(A) – Medical Assessment / TB Documentation - Resident medical assessments, including documentation for communicable tuberculosis, were missing from resident files. Plan of Correction not met. 10. 87211(a)(1)(A), (B), & (D) – Unusual Incident Reporting- LPA reviewed records and confirmed that hospitalization of Resident #1 (R1) on 10/07/2025 and 10/22/2025–10/31/2025 were not reported to CCL within seven (7) days as required. Administrator confirmed no reports were submitted. Plan of Correction not met. 11. 87465(h)(2) – Locked Medication Storage- LPA observed centrally stored medications for residents and staff stored unlocked in kitchen cabinets, drawers, staff room, and resident bedrooms, accessible to residents in care. Plan of Correction not met. Deficiencies issued and appeal rights explained. Exit interview conducted and copy this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Jan 16, 2026

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff (S2) working without a proper fingerprint cleareance which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator has agreed to have S2 get fingerprinted by the POC due date. Administrator will provide an updated LIC500 to reflect new staff.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(3) · Plan of correction due date: Jan 16, 2026

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working,....a licensed facility: (3) Request a transfer of a criminal record....in Section 87355(c) or This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff members (S1) not being associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator has agreed to have S1 associated with the facility by the POC due date. Administrator will provide an updated LIC500 to reflect the associated staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Jan 22, 2026

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in having bedroom #3 emergency exit, activity room exit and main exit blocked by a trash can, a basket, and a dog which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Administrator agreed to remove the obstructions from the emergency exits and submit a photo to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.618(c)(3) · Plan of correction due date: Jan 22, 2026

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training...This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in not having a valid CPR/first aid training for a the staff available at the shift which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator agreed to obtain a valid CPR/first aid training for S1 and S2 and submit a proof to LPA by POD due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(a) · Plan of correction due date: Jan 22, 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...... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in not having a proper designee at the facility who can assist with LPA to provide documentsthe state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Administrator agreed to have a knowledgeable designee for the facility during their absense to provide all neccessary documents/records and submit a proof to LPA by POC due date. for residents and staff upon request which poses/posed a potential health, safety or personal rights risk to persons in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(f) · Plan of correction due date: Jan 22, 2026

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary.....: This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in two (2) out of two (2) staff files not available to LPA for audit and review which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator agreed to maintain all personnel records of all employees at the facility and provide to LPA upon request. Administrator will inform LPA by POC due date that all personnel records are available at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g) · Plan of correction due date: Jan 22, 2026

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in two (2) out of two (2) staff files not maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The administrator agreed to review all personnel files and correct missing documentation for all staff including the Administrator. The Administrator will inform LPA by POC due date of the files at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Jan 22, 2026

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in three (3) out of three (3) residents files/records not available for audit at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Administrator agreed to complete and update all three (3) residents facility files/records and inform LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(c)(1)(A) · Plan of correction due date: Jan 22, 2026

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnose......for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in three (3) out of three (3) residents did not have any records of TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Administrator agreed to provide all (3) residents medical assessment TB test results by POC due date to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)A,B&D · Plan of correction due date: Jan 22, 2026

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to ... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and review of the hospital discharge records conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalizations on 10/07/25 and 10/22/25, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's two incident reports (hospitalizations) shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 16, 2026

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible.........This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in all the residents and staff medications were accessible in the kitchen drawer, staff room, and bedroom #3 (resident) which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The administrator agreed to provide a vendorized training to all staff including the Administrator and will provide a copy of the training log, attendance sheet, training topic and name of the instructor will be submitted to the Licensing Agency by 01/16/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 16, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose .... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in having all cleaning supplies, laundry detergents, a scissor, and knives unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Administrator will provide a training to all staff on the importance of maintaining sharps, medications, toxins, inaccessible to residents in care. The administrator shall submit staff sign in sheet with the topic and the training material to LPA by POC date. The Administrator will also provide a proper locking mechanism at the facility.

Type of visit: Required - 1 Year

At 9:45 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff #1 (S1) Cirila De La Cruz and staff #2 (S2) Emmanuel Lima and the Administrator Florence Perigrino was contacted via a telephone. LPA explained the reason for the visit. The Administrator informed LPA that they are unable to come to the facility; however, designated the staff to conducted today's visit. The physical tour was conducted with the staff and LPA observed the following: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps were observed to be unlocked in a kitchen cabinet and accessible to residents. LPA was informed that all sharps are kept unlocked all the times and the staff was never told to keep the knives locked. LPA also observed cleaning supplies, a screw driver, and a hammer unlocked in the kitchen cabinet and accessible to residents in care. A Fire Extinguisher was last purchased hanging on the wall in the by between the kitchen and laundry area. It was purchased on 10/04/2025. Medication: The medications for staff and residents were observed in the kitchen drawer and cabinet and LPA observed that staff and residents medications are unlocked and accessible to residents in care. The staff informed LPA that the medications always remain unlocked. LPA observed medications in the staff room and the staff room was observed unlocked and accessible to residents in care. More medications were observed unlocked in bedroom #3. Continue on LIC809-C BEDROOMS: There are four (4) bedrooms designated for residents use. All bedrooms have sufficient closet space and have sufficient lighting. All bedrooms were observed to be properly furnished with appropriate beddings and linens. Facility has a live-in staff at the facility. The designated bedroom for the staff is bedroom (1); however, the staff is currently using bedroom #4. LPA observed room #4 unlocked and accessible to residents in care with their prescribed medication unlocked. In bedroom #3 LPA observed a scissor and resident's medication accessible and unlocked to residents in care. LPA also observed the emergency exit being blocked by a trash can and a basket. BATHROOMS: There are total of three (3) bathrooms and LPA observed all bathrooms to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed bathroom to have appropriate grab bar and a non-skid mat . The water temperature was noted at 125.4°. The facility is using one of the bathrooms attached with bedroom #1 for staff and visitors only. COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 70°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility. LAUNDRY ROOM: The laundry room is located behind the kitchen which has an entry to garage. LPA observed a door with a lock; however, it was observed unlocked with all laundry detergents unlocked and accessible to residents in care. The washer/dryer appear to be in good condition. SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observe a covered shaded area for residents. There is no swimming pool or bodies of water in the facility. One of the main exits in the activity room of the facility which leads to the main emergency exit of the facility was observed locked and inaccessible due to a dog. The Administrator informed LPA via a telephone that none of the staff or residents are allowed to use that exit. The exit was obstructed and blocked by a dog. Continue on LIC 809C SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational. Activity Room: LPA observed an activity room for residents use with an adequate amount of activities. The activity room is located in the back of the house adjacent to living and dinning rooms. Records: Upon request of the staff and residents records/facility files, LPA was only provided with partial records for Resident #1 (R1) and LPA reviewed two other residents files and observed only the admission agreement and ID information for R2 and for R3 only an admission agreement on file. Moreover, LPA was informed the S1 have been working at this facility since 10/22/2025 and S2 is working since December of 2025. However, LPA reviewed LIS and Guardian and did not observe S1 being associated and S2 being finger print cleared and associated with the facility. LPA also did not observe any staff training records and LPA was informed that no staff training are conducted. Additionally, LPA observed that Resident #1 (R1) was taken to the hospital on 10/07/2025 and again on 10/22/2025 through 10/31/2025 for urinary tract infection; however, no incident reports were submitted to Community Care Licensing Division (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. Administrative: LPA collected liability insurance certificate. During today's inspection, the facility is not in compliance with Title 22 regulations. Deficiencies will be cited for today's visit. Appeal rights explained Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 5, 2026

Type of visit: Required - 1 Year

At 12:10 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with Betty Griego, the staff LPA and explained the reason for the visit. LPA was informed that the Administrator cannot come to the facility due to a full-time job. Physical tour was conducted with the staff and LPA observed the following: Upon arrival LPA was informed that the census is zero (0); however, the facility did have a resident from end of March 2024 to June 1st, 2024. LPA was informed that R1 had difficulty breathing on or before 06/01/2024, and R1 passed away. However, no death report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of 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 cabinet and inaccessible to residents. Fire Extinguisher was last purchased on 09/12/23, and was full. The medication will be kept in a locked cabinet in the kitchen. BEDROOMS: There are four (4) bedrooms designated for residents use. All bedrooms have sufficient closet space and have sufficient lighting. All bedrooms were observed to be properly furnished with appropriate beddings and linens. Facility has a live-in staff at the facility. The designated bedroom for the staff is bedroom (1); however, the staff is currently using bedroom #4. Continue on LIC809-C Administrative: LPA was informed that the facility does not have a Certificate of Liability Insurance, LPA was not provided LIC 500. During today's inspection, the facility is not in compliance with Title 22 regulations. Deficiencies will be cited for today's visit. Appeal rights explained Exit interview conducted. Copy of report provided. BATHROOMS: There are total of three (3) bathrooms and LPA observed all bathrooms to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed bathroom to have appropriate grab bar and a non-skid mat . The water temperature was noted at 119°.3. The facility is using one of the bathrooms attached with bedroom #1 for staff and visitors only. COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 72°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility. LAUNDRY ROOM: The laundry room is located behind the kitchen which has an entry to garage. LPA observed a door with a lock. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observe a covered shaded area for residents. There is no swimming pool or bodies of water in the facility. The facility has a back-house and the owner of the house lives in it. No residents wre observed in the back house. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational. Activity Room: LPA observed an activity room for residents use with an adequate amount of activities. The activity room is located in the front of the house adjacent to living and dinning rooms. Records: Upon request of the records for staff, LPA was not provided with any records. Moreover, LPA was informed the S1 have been working at this facility since 04/20/2024. However, LPA reviewed LIS and did not observe S1 being associated with the facility. The facility had a resident from March 2024 to June 1st, 2024. LPA requested for the former resident file and LPA was not provided with one. Continue on LIC 809Cthe state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Prelicensing

At 9:00 am, Licensing Program Analysts (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Administrator Katrin Beikjian and the owner Mineli Manukian. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did not observed any residents present in the facility. Fire Clearance dated 10/17/2023 and received for five (5) Non-ambulatory and one (1) Bedridden (room #3) residents. 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 LPA touring the physical plant inside and outside and observed the following: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of 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 cabinet and inaccessible to residents. Administrator/Licensee was informed that the locking mechanism shall be maintained and inaccessible at all times. Fire Extinguisher was last purchased on 09/12/23, and was full. The medication will be kept in a locked cabinet in the kitchen. BEDROOMS: There are four (4) bedrooms designated for residents use. Bedroom (3) is Bedridden and three (3) are Non-ambulatory. LPA observed a model which was furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. and chest drawers. Facility will have a live-in staff at the facility in the bedroom (1). Bedroom # 4 and bedroom # 5 are shared. All bedrooms have a functional alarm system. . Continue on LIC809-C BATHROOMS: At 9:47am LPA observed bathroom # 1 is clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed bathroom to have appropriate grab bar and a non-skid mat . The water temperature was noted at 119°.3. The facility is using bathroom # 2 for staff and visitors only. COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 72°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility. Office Area: LPA observed an office area between dinning room and kitchen. The residents and staff file will be kept in a locked chest drawers. LAUNDRY ROOM: The laundry room is located behind the kitchen which has an entry to garage. LPA observed a door with a lock. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observe a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There is no swimming pool or bodies of water in the facility. The facility has a back-house which will have no residents and the owner of the house will live in it. The back-house will be kept locked all the times when the owner is away. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational. Activity Room: LPA observed an activity room for residents use with an adequate amount of activities. The activity room is located in the front of the house adjacent to living and dinning rooms. Component III was conducted with the Administrator.the state’s words, verbatim · CDSS document, Dec 12, 2023