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Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit and met with the Applicant Armenuhi Avestisyan. This is a new facility application for a Residential Facility for the Elderly (RCFE) for six (6) non-ambulatory residents; one (1) of which may be a bedridden resident(s) and approved to reside in bedroom #3. Fire Clearance was approved on 01/08/2026. Bedridden room #3 approved. LPA Urena and the Applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility will be following Title 22 Regulations. COMMON AREAS: The living room area is equipped with a television and comfortable furniture. There is a dedicated area for the posting of required documents at the entrance of the facility. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. Medications will be stored in a locked cabinet in the kitchen area. The residents’ and staff files will be stored and locked in a file cabinet located in the corner of the living room area. A fire extinguisher is located near the main door entrance, which was purchased on 01/07/2026. The Applicant will create Emergency Evacuation Floor Plans and will post them in at least four (4) locations: Common Area, Kitchen Area, and on the walls outside rooms #1 and room#3. KITCHEN: Kitchen knives are locked and inaccessible in a locked kitchen cabinet. A seven-day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean, and all appeared functional. Kitchen cleaning supplies will be stored and locked under the kitchen sink. Hot water temperature was recorded at 117.5 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. A fire extinguisher is located near the kitchen cabinet, which was purchased on 01/07/2026. BATHROOMS: There are three (3) bathrooms. One half restroom with toilet and sink is located in the hallway, between Kitchen door and laundry area. The second bathroom is a full bathroom designated for “Staff” only. A full bathroom is located near room # 3 and is for residents’ use. All bathrooms are equipped with toilets and shower grab-bars, and non-skid mats. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered was between 107 and 115 degrees Fahrenheit. LAUNDRY: There is a laundry area equipped with washer and dryer. The washer and dryer are located in the hallway between the restroom and room # 1. Detergents and cleaning supplies will be stored in a locked with the washer and dryer area. SURROUNDING GROUNDS/OUTDOOR AREA: The exterior passageways were clean. The patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents and visitors. Left passageway is cleared and has a self-latching gate. A piece of wood covering an opening on the ground on the side cleared for fire exit will be secured to prevent residents from moving it and falling into the opening. Pre-Licensing is incomplete with deficiencies to be resolved by 06/01/2026. Follow up Pre-licensure LIC809 will be generated upon resolution. · The Applicant will create Emergency Evacuation Floor Plans and will post them in at least four (4) locations: Common Area, Kitchen Area, and on the walls outside rooms #1 and room#3. · Rooms #1, and #2 require drawer space to satisfy the minimum 8 cubic ft. of drawer space. Room #3 requires drawer space to satisfy the minimum 8 cubic feet of drawer space for one resident. Closet space was observed to be sufficient in all three rooms. · A piece of wood covering an opening on the ground on the side cleared for fire exit will be secured to prevent residents from moving it and falling into the opening. The applicant completed Component III orientation. 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. Exit interview was conducted and reviewed with the applicant. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 28, 2026

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 06 Census : 0 Method: Telephone call with CAB COMP II Participants: SAROYAN, SONA; AVETISYAN, ARMENUI Administrator/Licensee participated in COMP II via telephone call with CAB analyst. Identification of the Administrator/Licensee was verified by confirming driver’s license number. During COMP II, Administrator/Licensee confirmed the understanding of Title 22. Component II was successfully completed. Administrator/Licensee was advised to email signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Administrator/Licensee'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, May 6, 2026