Horizon Assisted Living Facility

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 9:47 am. LPA disclosed to the administrator the purpose of the visit. LPA conducted a tour of the physical plant at approximately 10:20 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs of residents. These included the kitchen/dining room combination, living room and family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Emergency food pantry in hall closet. Sharps are stored in locked bottom kitchen cabinet. The resident medications were stored in locked top kitchen cabinet and observed to be inaccessible to residents. The first aid kit on top of refrigerator. There is one (1) fire extinguisher attached to wall in the kitchen and observed to be charged. Laundry room is located adjacent to kitchen. The appliances observed to be functional. Toxins stored above in locked cabinet above washer and dryer were observed to be locked and inaccessible to residents. The facility has a total of five (5) bedrooms and four (4) bathrooms: One (1) shared and four (4) private bedrooms; three (3) bathrooms for residents use and one (1) bathroom for staff. The residents’ bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet. Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 108-118 degrees Fahrenheit. Detached Garage: Used for storage and has 2nd refrigerator. Smoke detectors/carbon monoxide detector were tested and operable at time of visit. Backyard has the following: Gazebo with sufficient seating for the residents. Foliage in backyard overgrown presents tripping hazard. Discussion of painting vs cleaning discussed due to excessive peeling on cabinets in hallway. At approximately 11:30 am, LPA reviewed files for the six (6) residing residents. Resident files included medical assessments and needs and services plans. Staff files reviewed for three (3) staff. Staff files had the appropriate trainings such as first aid and hospice in session training. Deficiencies on cited 809D. Exit Interview Conducted / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Mar 11, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tihesha Smith conducted a Case Management visit at the above facility at 09:15 am to verify that Resident #1 (R1) and Resident #1 (R2) relocated to the facility on 08/16/25 and to do a health and safety check on both residents. LPA met with staff and explained the purpose for the visit. The administrator was contacted by staff and arrived later. At approximately 9:45 am, LPA Smith conducted a brief tour of the physical plant to ensure compliance with Title 22 regulations. Prior to the visit on 08/19/25, LPA Smith requested via email, new admissions information for the facility and an updated client roster. The client roster was received on 08/22/25 and a printed copy was provided during the visit. During the physical plant tour, LPA checked the facility and R1’s and R2’s room. A brief interview was conducted with R1 and R2. Both residents were awake, dressed and alert, however, per administrator, R1 is hearing impaired. Both residents expressed they are doing satisfactory or okay. R1 revealed would like dental care and R2 revealed they do not have any concerns or issues. A brief discussion with the administrator revealed she has contacted/and is working with R1 responsible party to resolve R1s concern. The administrator authorized Klaris Throhain to sign report. LPA did not observe any deficiencies or hazards during the visit. Exit interview conducted. A copy of the report given.the state’s words, verbatim · CDSS document, Aug 22, 2025

Type of visit: Required - 1 Year

At approximately 9:50 a.m. on 04/03/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator designee and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 03/16/2024 for an annual inspection. It is a single story building with five (05) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which 1 may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). LPA observed a maintained front yard and postings near the main entrance for the facility’s COVID policies, emergency contacts, confidential complaint contacts, Ombudsman contacts, personal rights, rights of resident councils, theft and loss policy, administrator certificate, facility sketch. LPA observed a screening station with digital thermometer, visitor log, sanitizer, masks, and additional PPE. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:15 a.m. LPA measured the room temperature to be 77 degrees Fahrenheit. The living room contained a television, reading materials, a locked fireplace, and furniture in good condition. Hallways closets contained emergency food and water and sufficient supplies of fresh linens. The facility has four (04) bathrooms. All bathrooms designated for residents contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid surface in the shower. At approximately 10:30 a.m. LPA measured the water temperature in the hallway bathroom to be 109.8 degrees Fahrenheit. The facility has five (05) bedrooms. All bedrooms were private rooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All hospital beds had wheels in the locked position. All furnishings were clean and in good condition. A Hoyer lift, full bed rails, and oxygen machine were observed in Bedroom #3. A sign for “No Smoking – Oxygen in Use” was posted on the door. A call system was in use for Bedroom #5 and routed to the kitchen. At 11:30 a.m. LPA called out from the house telephone which was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked above a counter top. Confidential files were locked below the counter top. A washing machine and dryer were located near the kitchen. Both were in working order and in use. The detergent was locked above the appliances. At approximately 11:35 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 02/06/25 with a receipt attached. The emergency exit path was free from obstructions. The exit gate on the north side of the facility was unlocked with a self-closing latch. The back yard was maintained. The patio furniture was shaded under a pergola and in good repair. Auditory alarms were turned on and functioning. The facility also uses a centralized auditory alert system. At approximately 11:55 a.m. smoke and carbon monoxide detectors were tested and operational. Detectors were hard-wired and functioned simultaneously when tested. At 12:00 p.m. LPA reviewed resident and personnel files. All files were available for audit. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 3, 2025

Allegation investigated: Facility is not allowing resident to move out of the facility Facility staff did not have the ability to communicate with resident Staff did not address a change in the resident's condition Staff did not assist resident with transfers

At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced subsequent complaint visit. LPA met with the staff who granted access to the facility and shorly after Administrator Sona Gevorkyan arrived and LPA disclosed the reason for the visit. A subsequent visit was conducted on 05/22/2024. During course of the investigation, interviews and record review were made. At 12:15 PM, LPA requested resident and staff roster. At 12:20 PM, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 12:35 PM, LPA conducted a physical plant tour. Between 12:45 PM to 2:00 PM, LPA conducted an interview with the Administrator, one staff, four (4) out of five (5) residents who were able to communicate, and a family member of a resident. Additional interviews and record reviews were also conducted during today’s visit. Continue on LIC 9099C Unsubstantiated Facility is not allowing resident to move out of the facility: It is alleged that the facility did not allow R1 to move out of the facility. To investigate this allegation LPA conducted interviews with the Administrator, one (1) staff, and four (4) out of five (5) residents who were able to communicate. Interview with the Administrator revealed that R1 did not have any family member or POA. R1 was admitted to the facility via referring agency. A random person that the facility had no record of came to the facility to take R1. The Administrator did not allow since there were no evidence of any kind of relation to R1. Additionally, Interview with four (4) out of five (5) residents did not have any issues moving out of the facility at any time they wanted. Based on interviews this allegation is Unsubstantiated at this time. Facility staff did not have the ability to communicate with resident: It is alleged that the facility staff are not able to communicate with R1 in Spanish. To investigate this allegation LPA conducted interview with the Administrator and one (1) staff. It was revealed that although the staff did not understand Spanish nor could speak it, yet they were able to understand R1 by using google translation application via their phones. Moreover, four (4) out of five (5) residents interviewed, revealed they can effectively communicate their needs with the facility staff without any issues. During the visit, LPA observed that all staff understand and can communicate with basic English to the majority of the residents who are communicating in English without any problem. Based on interviews and LPA’s observation this allegation is Unsubstantiated at this time. Staff did not address a change in the resident's condition: It is alleged that R1 lost weight due to lack of care. To investigate the above allegation LPA conducted an interview with the Administrator and as informed that when R1 was admitted to this facility, R1 was already receiving Hospice services due to his/her medical condition. Moreover, review of hospice file indicated that R1 was on a mechanical soft diet and was able to tolerate thin liquid with total of 25% oral meal intakes, and due to slow and steady decline R1 was hospice appropriate; However, it was determined/ordered by hospice doctor to discharge R1 from hospice on 12/28/2022 and admit R1 to the hospital for further evaluation. On 1/1/2023 R1 returned to the facility and was admitted back to receiving hospice services. During today’s visit, LPA was provided with the hospice doctor’s order dated on 12/28/2022. Based on interviews and record reviews this allegation is deemed Unsubstantiated at this time. Continue on LIC 9099C Staff did not assist resident with transfers: It is alleged that R1 cannot go outside because there are no staff to take R1 outside. To investigate this allegation LPA conducted interviews with the Administrator and one (1) staff and all parties dined the above allegation. Moreover, interviews with four (4) out of five (5) residents did not have any concerns regarding the above allegation. During the time of both visits on 05/22/2024 and as well on 07/30/2024, LPA observed that the staff are helping residents with transfers and other assistance they need. Based on interviews and LPA’s observation this allegation is deemed Unsubstantiated as this time.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 31-AS-20221228133054

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Kiiashko Dmitro for a Required One (01) Year visit. LPA explained the reason for the visit. The administrator, Sona Gevorkyan, designated Kiiashko Dmitro to sign and accept this report. A tour of the physical plant was conducted at 12:20 PM and the following was noted: There is one entrance being utilized at the facility. The facility has a total of five (05) bedrooms and four (04) bathrooms. The facility is fire cleared for five (05) non-ambulatory, of which one (01) may be bedridden and a hospice waiver for four (04). The facility is currently occupying five (05) non-ambulatory residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen near the office desk, observed to be full and last inspected on 01/30/2024. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 111.7°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 16, 2024

Allegation investigated: Staff gave resident unapproved dietary drinks

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility on 11/13/2023 to deliver findings. On 06/29/20223 this case was referred to the Community Care Licensing Investigations Branch (IB). Investigator Christine Ferris continued the investigation by conducting records review and interviews on 08/01/23, 08/04/23, and 08/30/23. A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023 and a subsequent visit on 10/31/2023. Staff gave resident unapproved dietary drinks Unsubstantiated (Cont from 9099C) It was alleged that staff gave Resident #1 (R1) unapproved dietary drinks. Interview with Administrator revealed they offered R1 an Ensure drink one time but R1 refused the drink. Staff revealed that they keep resident hydrated at all times with water. Other witnesses interviewed during investigation revealed that they saw a “two-liter bottle” of water by R1. Due to finding no evidence that the offered dietary drinks were ingested there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 31-AS-20230629104943

Allegation investigated: It was alleged that Resident sustained multiple ulcer wounds while in care Staff did not seek timely medical care for resident.

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 10:10 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was present at the facility. A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023, at which time LPA Smith conducted a physical plant tour at approximately 11:20 am and conducted an interview with the administrator. On 06/29/20223 this case was referred to the Community Care Licensing Investigations Branch (CCIB). Investigator Christine Ferris continued the investigation by conducting records review and interviews on 08/01/2023, 08/04/2023, and 08/30/23. (Cont to 9099C) Substantiated (Cont from 9099A) Staff did not ensure resident was hydrated. It was alleged that due to severe dehydration R1’s health condition got more complicated. Staff revealed that they keep resident hydrated at all times. Between 06/23/23 and 06/25/23 R1 was having swallowing difficulties but was able to intake fluids. Staff informed hospice services and staff also spoke to R1’s responsible party, who called 911. A review of hospice records revealed that R1 ate and drank regularly. R1 was assessed for hydration during skilled nursing visits and there were no signs of dehydration. Other witnesses interviewed during investigation revealed that they saw a “two-liter bottle” of water by R1. Due to finding no evidence to suggest fluids were withheld or any actions or lack thereof by staff contributed to R1s dehydration, there is not sufficient information to support the allegation, Therefore, the above stated allegation is determined to be unsubstantiated at this time. Staff did not observe a change in resident's condition It was alleged that Staff did not observe a change in R1s condition. Interviews with staff on 06/30/23, 10/31/2023, and interviews conducted during the course of the investigation reveal that staff noticed R1’s wounds not healing. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety. Based on interviews and records review staff monitored R1s condition and noticed changes in R1s condition consequently there is insufficient information to support the allegation. Therefore, the above stated allegation is determined to be unsubstantiated at this time. Exit interview conducted/Appeals/Copy of report given. (Cont from 9099) It was alleged that Resident sustained multiple ulcer wounds while in care. Staff interviews conducted on 08/01/2023, revealed that upon admission to the facility, staff assisting Resident #1 (R1) noticed a black bloody spot on R1’s coccyx. The spot felt hot like it was burning. Staff was repositioning and turning R1 every 2 hours. Interviews also revealed that although a “small, black spot” was noticed near R1’s coccyx, staff did not know “what was under the tissue,” but it was “deep when the skin opened on 06/13/2023”. A review of hospice/palliative and wound care records conducted by the IB investigator revealed that while in care at the facility, R1 developed pressure injuries. As of 06/13/2023, the pressure injuries were staged as Stage 4. Although R1 was receiving wound care by medical professionals between 06/13/23 to 06/25/23, the conditions of the wounds got worse. Records revealed that a sacral stage 4 pressure injury was addressed and subsequently treated by the wound specialist. However, other Stage 4 pressure injuries noted in hospice records, were not addressed by medical professionals. IB investigators review of the hospital records revealed,that on 06/27/2023, R1 was admitted to the hospital with multiple Stage 4 pressure injuries on sacrum, Stage 4 pressure injuries on the left and right buttock. R1 was diagnosed with sepsis (secondary to the buttock wound infection). In addition, R1 had several deep tissue pressure injuries. Overall, the investigation revealed that although facility staff including the Administrator had knowledge that R1’s pressure injuries were not healing, they failed to obtain all required information from the hospice agency and take appropriate measures to ensure that there is no immediate threat to the health and safety of the resident. Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time. Staff did not seek timely medical care for resident. It was alleged that R1’s overall health condition was declining, and staff failed to provide emergency medical assistance on time. Staff revealed that as of 06/14/2023, they noticed that R1 was having swallowing (Cont to 9099C) (Cont from 9099C) difficulties and developed prohibited health conditions, posing immediate danger to R1’s health and safety. Staff admitted not contacting emergency services. Between 06/14/2023 and 06/27/2023 R1’s condition got worse. R1’s responsible party was contacted, and 911 was called by R1’s responsible party. A review of the medical records verified the information received from the staff. Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 31-AS-20230629104943

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Nov 2, 2023

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on record reviews & interviews, R1 wounds not healing, developed unstageable wounds while in care which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Licensee shall submit a written plan describing how the facility shall prevent injuries to residents in care as a result of this deficiencies. Licensee shall submit to CCL no later than 11/02/2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Nov 2, 2023

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited, as staff did not seek medical attention for R1 in a timely manner, which posed an immediate health and safety risk to R1the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: The Administrator agreed to do the following: Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening and to ensure compliance to the cited regulation Licensee shall submit to CCL no later than 11/02/2023

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.