In Home Care Center

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced case management visit to address deficiencies. LPA Smith was greeted by staff and disclosed the reason for the visit. The administrator was contacted and arrived later. On 10/09/25, LPA Smith discovered deficiencies during the annual visit, but due to database issues, the deficiencies could not be issued. The following was observed on 10/09/25: Patio furniture (sofa) was severely worn, with large cracks, tears, revealing the white fiber filing inside Pile/collection of trash/recycling and grocery store carts in backyard. Administrator provided pictures later the same day that items have been corrected. Therefore, under Title 22 Regulations, the following deficiency was cited and recorded on LIC 809D. Exit interview conducted and a copy of the report issuethe state’s words, verbatim · CDSS document, Oct 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 9, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. [...] This requirement was not met based on observed worn sofa during annual inspection on 10/09/25the state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: Per administrator will remove sofa and purchase new outdoor furniture Cleared same day as visit 10/09/25

From the deficiency page — Deficiency type: Type B · Section cited: CCR80088(f) · Plan of correction due date: Oct 9, 2025

(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, [...] This requirement was not met based on observed pile of recycling/trash and grocery store shopping carts during annual inspectionthe state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: Per administrator items will be dumped/removed. Cleared same day as visit 10/09/25

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 10:35 am. LPA was greeted by the staff and disclosed the purpose of the visit. The administrator was contacted and arrived later. LPA conducted a tour of the physical plant to ensure there are no health and safety hazards, and the facility is following Title 22 Regulations. Common areas, which include the kitchen and the combined living and dining room, were evaluated for their ability to safely meet residents' needs. These spaces were inspected for cleanliness, and furniture was assessed for functionality and condition. All common areas were found to be clean, sanitary, and furnished with seating sufficient to accommodate residents comfortably. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with frozen foods. The resident medications are locked in standalone cabinet and observed to be locked and inaccessible to residents. There is one (1) fire extinguisher located in living room attached to wall. Fire extinguisher observed to be charged. Laundry room is located in separated room at side of kitchen. The appliances observed to be functional. The locked cabinets in laundry room store toxins and cabinets in laundry area observed to be locked and inaccessible to residents. The facility has a total of three (3) bedrooms and two (2) bathrooms for residents in care. 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, and blankets. Main bathroom has the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the bathroom to ensure it is within the required range for residents’ comfort and safety. The water temperature range was 117.0 -degrees Fahrenheit. LPA Smith observed sink in 2nd bathroom removed. Backyard has the following: Table and chairs, and small L shape couch. Patio furniture was observed to be in good repair with the exception of the L shaped couch. Couch worn with large cracks, tears and white exposed filling. Administrator/staff states will have couch removed. Attached Garage: Used for storage/PPEs carbon monoxide and smoke detectors were tested and operable at time of visit. Facility grounds were free of hazards. However, store shopping carts and bags of recycling were observed. Items will be removed. At approximately 01:20 pm, LPA reviewed five (5) resident files and three (3) random staff files. Resident files included admissions agreements and needs and services assessments. Staff files had the appropriate training courses to include CPR and first aid. Deficiencies will be addressed on case management visit. Exit Interview Conducted /Copy of the Report Issued.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Kristine Dovlatyan for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:30 AM and the following was noted: There is one entrance being utilized at the facility. The facility has a total of three (03) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden. The facility is currently occupying four (04) 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 78°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the dining area and observed to be fully charged and last inspected 03/18/2024. (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 115.3°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 12, 2024

Allegation investigated: Resident sustained multiple pressure injuries while in care Staff do not have accurate records for a resident Staff did not abide to the admission agreement

Licensing program analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to deliver findings. The administrator was contacted and arrived later. LPA Smith met with the administrator and disclosed the purpose of the visit. During the initial visit on 04/06/24, LPA Jose Gary Tan conducted physical plant tour at 9:15 AM, requested copy of facility documents relevant to the investigation at 9:43 AM and interviewed staff and resident between 9:45 AM to 11:30 AM. On 01/16/24, LPA Tihesha Smith conducted a subsequent visit and interviewed four (04) residents, four (04) staff and reviewed records from 10:50 am – 1:05 pm. Resident #1 (R1) is no longer a resident at the facility and Resident # 6 (R6) unable to speak due to condition. Resident sustained multiple pressure injuries while in care It was alleged that facility resident #1 (R1) sustained multiple skin injuries causing extreme discomfort. Unsubstantiated (cont. from 9099) Licensing Program Analyst (LPA) Tihesha Smith and Naira Margaryan conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation on 05/23/2024. Staff denied being neglectful in R1’s care. Interviews revealed that R1 was admitted to the facility with red blisters all over their body. Resident was admitted to the facility with assigned hospice services. Although the Administrator was informed that the red blisters on R1’s body are not infected and will not transfer to others, the Administrator sent R1 to the hospital. R1 returned to the facility within 2 hours per discharge records and R1 had a chronic condition: “adult rush” requiring daily treatment. The Administrator stated that R1 was in the facility for one (1) week and within that week due to discomfort, R1 went to the hospital 3 times. On 03/28/23, R’s condition was discussed with the discharge nurse at the hospital and the decision was made to transfer R1 to a Skilled Nursing Facility. A review of the facility records verified the information revealed by the staff. There was no information or evidence available during this investigation to conclude that R1 sustained multiple pressure injuries due to neglect. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. Staff did not have accurate records for resident. It was alleged that staff did not have accurate records for residents. Interview with the administrator revealed that she had all required documents for each resident. A review of the records including R1’s facility file, revealed that although the files were not organized, all required documents were present in folders designated for each resident. Due to no information available to support the allegation, therefore, based on observation and record review the allegation is UNSUBSTANTIATED at this time. Staff did not abide to the admission agreement It was alleged that credible witness observed lack of appropriate admission and discharge documentation. (Cont to 9099C) (cont from 9099A) Staff did not properly safeguard the residents’ medications It was observed that staff #1 (S1) pull out R1’s medication from the unlocked closet in R1’s room to assist R1. At the time of this visit at 2:30pm LPM Margaryan interview S1 in Armenian and she verified the information alleged by the complainant. LPM Margaryan also inspected R1’s room and S1 was able to show a storage space where she was and is currently keeping peroxide solution for R1. Based on interview and observation there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Resident's admission agreement has been forged while in care It was alleged that Resident's admission agreement has been forged while in care. A credible witness observed that the dates on R1’s admission agreement were forged. A review of R1’s admission agreement verified the allegation. There was information or evidence available during this investigation to conclude that Resident's admission agreement has been forged while in care therefore, based on record review and credible witness, the allegation is SUBSTANTIATED at this time. Deficiencies cited on 9099D Exit inteview conducted/copy of report given. (Cont from 9099C) The Administrator stated that she always keeps appropriate documents for all resident’s admission and discharge.She indicated that she is not only keeping admission and discharge records from the facility but also from the hospital and following doctors’ instructions and following all items outlined in the admissions agreements. A review of facility records verified the information received from the Administrator. Due to no information available to support the allegation, therefore, based on observation and record review the allegation is UNSUBSTANTIATED at this time. Exit interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 31-AS-20230405164319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(B) · Plan of correction due date: May 23, 2024

Incidental Medical and Dental Care. (h) (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed This requirement was not met based on observation and interviews medication was not properly stored which posed a health and safety risked for residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2024

Plan of correction: See Correction below The licensee moved the perixode on day of visit: 05/23/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 23, 2024

(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 was not met based on observation and interviews that dates on files were overwriten/crossed out which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2024

Plan of correction: The licensee will provide a written statement of understanding of how documents should be corrected or updated moving forward. POC date:06/20/24

Allegation investigated: Staff neglect resulted in a resident to be hospitalized while in care Staff did not properly report an incident involving a resident

Licensing Program Analyst (LPA) Tihesha Smith and Naira Margaryan conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation on 05/23/2024. The administrator was contacted and arrived later. Licensing staff met with the administrator Kristine Dovlatyan and disclosed the purpose of the visit. Staff neglect resulted in a resident to be hospitalized while in care It was alleged that staff neglect resulted in a resident to be hospitalized while in care. To investigate this allegation, during initial visit on 03/06/2023, LPA Smith conducted a physical plant tour, interviewed the administrator, and obtained and requested copies of documents relevant to the investigation. Interview with the administrator revealed that on 01/21/2023 by recommendation from Resident #1 (R1) doctor, R1 was taken to the hospital by the administrator due to weakness, dark urine and odor. Administrator drove R1 to the hospital in personal vehicle and R1 was able to ambulate to the car and get in without Unsubstantiated (Cont from 9099) assistance. The administrator was instructed by the doctor to contact them upon arrival. Administrator disclosed that R1 was admitted to the hospital after she took him there. Administrator also revealed followed up with hospital, but hospital staff only disclosed that since R1 would not be returning to the facility they will not provide any information regarding the status of R1. Based interview although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Staff did not properly report an incident involving a resident It was alleged that staff did not properly report an incident involving a resident. Review of records on 03/06/23 reveal that incident reports are faxed within required timeframe and a copy of the incident report form is kept in resident records. Interview with administrator revealed resident’s responsible parties are contacted, licensing notified (and additional agencies if any). Based interviews and record review although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, May 23, 2024 · control 31-AS-20230227123033

Allegation investigated: Staff did not prevent resident from eloping from facility

Licensing Program Analyst (LPA) Tihesha Smith and Naira Margaryan conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation on 05/23/2024. The administrator was contacted and arrived later. Licensing staff met with the administrator Kristine Dovlatyan and disclosed the purpose of the visit. Staff did not prevent resident from eloping from facility It was alleged that Staff did not prevent resident from eloping from facility. To investigate this allegation, during initial visit on 03/06/2023, LPA Smith interviewed the administrator, staff and requested documents relevant to the investigation from approximately 12:45 pm am to 2:10 pm. Resident # 1(R1) is no longer at the facility. Interviews with the administrator reveal Resident #1 (R1) did not elope from the facility. Administrator notes that all windows, and doors of the facility have alarms that chime when they are Unsubstantiated (Cont from 9099) opened and there are cameras around the facility that also record activity on the facility and no residents have been recorded leaving the facility. Three (3) of three (3) staff reveal will they respond immediately when any chime sounds within the facility. They immediately check inside and outside the facility including all cameras. LPA Smith checked the facility windows, and doors, and observed all sensors to be active and chimed audibly when opened. Chimes were also rechecked during today's visit and can be heard through out the facility. Based interviews and observation although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, May 23, 2024 · control 31-AS-20240410095157

Allegation investigated: Due to neglect, resident was dehydrated

At 9:50 a.m. on 04/03/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, initial complaint visit. LPA met with Staff #1 (S1) and later the administrator and disclosed the reason for the visit. Regarding the allegation “Due to neglect, resident was dehydrated” it as alleged Resident #1 (R1) was neglected and not provided adequate hydration. To investigate the allegation, LPA toured the facility at 10:00 a.m. today, conducted a file review of pertinent records at 10:30 a.m. including but not limited to the staff list, resident list, medical assessment, and care notes, and interviewed the administrator, two (02) staff, a nurse, and one (01) out of four (04) residents between 11:00 a.m. and 12:30 p.m. Interview with the administrator at 11:00 a.m. today revealed R1 often refused bathing, grooming, and feeding support. Staff called 9-1-1 for R1 on 03/24/2024 due to low blood pressure and malnourishment. Unsubstantiated Interview with Staff #2 (S2) at 11:30 a.m. today revealed R1 refused staff attempts to feed and provide fluids to R1 on 03/23/2024. Staff reminded R1 of the importance to eat and drink fluids. Staff provided a variety of options for R1, but R1 only drank a little juice and ate no food. Interview with Resident #2 (R2) at 12:00 p.m. today revealed staff provide sufficient care and supervision to the residents in the facility. Interview with a hospital nurse at 12:30 p.m. today revealed R1 suffered from confusion and would not accept food or fluids, so a feeding tube was provided. Record review confirmed R1 had a history of refusing care at the facility. Based on interviews and record review, staff provided adequate care and supervision, and R1 refused care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 3, 2024 · control 31-AS-20240326144618

Allegation investigated: Staff did not ensure a resident was properly fed while in care

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with the administrator Kristine Dovlatyan and disclosed the purpose of the visit. During initial visit, on 03/06/2023, LPA Smith conducted a physical plant tour, interviewed the administrator, and obtained and requested copies of documents relevant to the investigation. Staff did not ensure a resident was properly fed while in care It was alleged that Resident #1 (R1) was not being fed. To investigate this allegation, LPA Smith conducted a physical plant tour at 10:40, interviewed four (04) residents, four (04) staff and reviewed records from 10:50 am – 1:05 pm. (R1) is no longer a resident at the facility and LPA unable to reach for an interview. Resident # 6 (R6) unable to speak due to condition. During interviews LPA observed lunch meal being prepared and staff informing residents lunch is being Unsubstantiated (cont from 9099) served. Interviews with four (4) out of four (4) staff revealed three (3) meals are served with a snack served in between meals. Two (2) out of two (2) staff reveal residents may refuse meal but a plate is always served. Interview with four (4) out of four (4) residents revealed received all meals when present at the facility. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 31-AS-20230227123033

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:45 am. LPA disclosed to staff the purpose of the visit and the administrator was contacted and arrived later LPA conducted a tour of the physical plant 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 residents. These included the kitchen, dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Sharps stored in top kitchen drawer, observed to be locked and inaccessible to residents. The resident medications are locked in standalone cabinet. The medications were observed to e inaccessible to residents. There is one (1) fire extinguisher located in living room attached to wall. Fire extinguisher observed to be charged. The facility has three (3) bedrooms and two (2) bathrooms: The resident bedrooms furnished with at least one chair, nightstand, and sufficient lighting for each resident. (cont. from 809) The bedrooms had appropriate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens stored in laundry room cabinets above washer and dryer. The hot water temperature was measured for the bathroom to ensure it is within the required range for residents’ comfort and safety. The water temperature range was 115.6 -degrees Fahrenheit. Surrounding Grounds: Entry/exits were free of obstruction. Sufficient seating for outdoor furniture. Laundry room is adjacent to kitchen. Appliances observed to be in good repair. Toxins stored in cabinets in laundry area observed to be locked and inaccessible to residents. Garage: used to store supplies and equipment At approximately 1:15 pm, LPA Smith reviewed five (5) resident files and five (5) staff files. Resident files included physician’s reports and Centrally stored meds. Staff files included current first aid and administrator license is current and posted. No deficiencies cited. Exit interview conducted/Copy of report giventhe state’s words, verbatim · CDSS document, Jan 8, 2024