Moon Light Boarding Care

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Daniel Konishi conducted a Health and Safety check visit. LPA met with the Staff, Adrine Adamian and LPA explained the reason for the visit. Reneta Manvelyan, staff arrived shortly after and LPA explained the purpose of the visit. The investigation consisted of: The facility which is a two-story home located in a residential neighborhood of Pasadena. LPA conducted a physical plant tour of the facility consists of a living/dining room area, a kitchen, four (4) resident bedrooms, four (4) resident bathrooms, one (1) staff/visitor's bathroom, a basement with a laundry area, a staff resting room and office on the second floor, a front porch, a backyard, and a detached garage. LPA observed the facility has sufficient 2-day perishable and 7-day non-perishable food supplies. LPA observed sufficient emergency food and water supplies. Based on LPA observation, the dining hall, activity room, library, kitchen, four residents’ bedrooms were clean, clear passageways, and had no obstructions. Extra linens and towels are observed in the hallway closet. LPA measured the hot water temperatures that were between 110.1 degrees F to 113.1 degrees which is within the required 105 degrees F to 120 degrees F regulations. Fire place is closed and inaccessible to clients. LPA observed the fire extinguisher is fully charged and was last inspected on 2/2/2026. Sharps are locked and inaccessible to residents. Cleaning supplies are locked and inaccessible to residents. Residents’ medications are centrally stored and locked in the kitchen cabinet. Carbon Monoxide Detectors were tested and are operable. No health and safety concerns were observed. Exit interview was held with the Staff, Reneta Manvelyan. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 3, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual visit today. LPA met with Sako Manvelyan, Administrator, and the reason for the visit was explained. The facility is licensed to serve (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a two-story home located in a residential neighborhood of Pasadena. The facility consists of a living/dining room area, a kitchen, (4) resident bedrooms, (4) resident bathrooms, (1) staff/visitor's bathroom, a basement with a laundry area, a staff resting room and office on the second floor, a front porch, a backyard, and a detached garage. During today's visit, the following was observed: The facility is clean inside and out. All passageways, walkways, exits and ramps are free of debris and obstructions. There are no pools or large bodies of water. Living room and dining area have sufficient seating for residents, and the furniture is in good repair. Exit doors are equipped with safety chimes and were observed to be working properly. Kitchen was observed clean and refrigerator, range and small appliances are operable and in good repair. There is sufficient food for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies, sharps and medications are kept locked in kitchen cabinets. Four (4) resident bedrooms were observed and have sufficient lighting, the required furniture, and bedding supplies. The (4) bathrooms were inspected and have grab bars and anti-skid mats. Water temperature was tested in each bathroom and measured between 109.2-117.4 degrees F., which is within the required 105-120 degrees F. Carbon monoxide and interconnected smoke detectors were tested and found to be operating appropriately. Laundry appliances were observed and are kept in good repair. Fire extinguishers were observed throughout the facility and are kept charged and operable. All required posters and signage were observed. Facility has a porch that provides a shaded area. Backyard is clean and garden is well maintained. The garage is kept clean and free of clutter. ***Continues on LIC 809-C*** An overflow refrigerator is kept in the garage and houses extra food for staff and residents. Incontinence care products, PPE and emergency water supply is also kept in the garage. LPA reviewed (3) resident and (3) staff files. Client and staff files contain the mandated documents. Safety drill records were also reviewed. The home conducts drills, quarterly. Last drill was conducted on 12/15/25 with staff and resident participation. The Emergency Disaster Plan was also reviewed and is up to date. Medication is centrally stored in the kitchen and kept locked in medication cabinet. Medication review was conducted for (3) residents and found to be dispensed according to physician’s orders and documented accordingly. During today’s visit, no deficiencies were noted, and no citations issued per Title 22 Regulations. Exit interview was conducted with Sako Manvelyan, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Asmik Avestisyan and explained the reason for the visit. The facility is licensed to served (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a single home located in a residential neighborhood and consist of a living/dining room area, a kitchen, (4) resident bedrooms, (4) resident bathrooms, (1) staff/visitor's bathroom, a front porch, a backyard, and a detached garage. LPA toured the facility with Asmik Avetisyan and observed the following: Facility is in good repair indoor and outdoor. All passageways are free of debris. There are no large bodies of water. Living room and dining room are furnished to provide seating area and activities for the residents. Activities were observed in the living room. Kitchen was observed clean and in working condition. There is sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies, sharps and medications are kept locked in kitchen cabinets. Four (4) resident bedrooms were observed with sufficient lighting, the required furniture, and bedding supplies. A total of (4) bathrooms were observed in working condition, with grab bars and skid mats. Water temperature was tested in each bathroom between 106.8-116.7 degrees F., which is within the required 105-120 degrees F. Carbon monoxide/smoke detectors were tested and are in working condition. Fire extinguisher was observed and last reviewed on 1/14/25. All requires posters were observed. Facility has a porch that provides a shaded area as well as a clean backyard. Laundry is located in the basement. Exit doors have an auditory device. LPA reviewed medication and files for 3 residents. There are currently zero (0) residents on hospice or with dementia. Resident #3(R3) is missing a TB test clearance. Bed rails were observed in the beds of Resident #1and #3 (R1/R3), no physician's request on file. (CONTINUED ON LIC 809C) LPA reviewed 2 staff files. Administrator's file was not at the facility at the time of the visit. Staff #3(S3) was missing TB clearance results on health screening, physician noted read date but did not note results. S3 was hired on 1/5/25 and has been working since January 14, 2025, there are no records of fingerprint clearance. Administrator certificate was reviewed for Sako Manvelyan #6066207740 exp. date: 9/8/25. LPA Flores reviewed infection control plan and emergency disaster plan. Last fire drill was conducted on 12/16/24 and are being conducted quarterly. Deficiencies are noted on LIC 809D per Title 22 Regulations. *Civil penalties were assess for $500.00 for background clearance.* Exit interview was conducted with Administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 4, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff do not meet resident's oxygen needs Staff do not treat resident with dignity

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Sako Manvelyan and explained the reason for the visit. The investigation consisted of the following: LPA requested staff/resident roster. Interviewed 3 residents and 2 staff, reviewed Resident’s #1(R1) file and requested copies of physician’s report, preplacement appraisal information, admission agreement, needs and care plan, and medication sheet and staff’s personal rights training. The investigation revealed the following: Regarding allegation: Staff do not meet resident's oxygen needs. It is alleged staff is denying R1's oxygen. Interviews with three residents revealed facility staff provide assistance as needed for as needed medication when residents have asked including oxygen. (CONTINUED ON LIC 9099C) Unsubstantiated However, one resident stated oxygen is provided but staff have stated they do not know how to place it in R1’s nose properly when providing it. Interviews with staff revealed staff assist R1 when oxygen is requested as needed and have not denied oxygen to R1. Interviews with R1’s family member revealed R1 is able to place oxygen properly as long as it is past to R1 and do not have concerns about facility providing oxygen. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not treat resident with dignity. It is alleged staff tells resident is being dramatic and does not assist resident. Interviews with residents revealed 2 out of 3 residents stated staff treat them and speak to them respectfully. 1 out of 3 residents stated that staff seem to be unhappy when providing care and facility staff do assist but have resident wait for care. LPA inquired on wait time for assistance, resident replied is about 5 minutes. Interviews with staff revealed staff respond to residents’ request as soon as possible. The only time they asked residents to wait is when they are assisting other residents. At which time they probably have the resident wait about 5 minutes before providing assistance. Facility staff stated to be respectful to residents. Facility staff received training on resident’s personal rights on April 12, 2023. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Sako Manvelyan and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240314100258

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with and explained the reason for the visit. The facility is licensed to served (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a single home located in a residential neighborhood and consist of a living/dining room area, a kitchen, (4) resident bedrooms, (4) resident bathrooms, (1) staff/visitor's bathroom, a front porch, a backyard, and a detached garage. LPA toured the facility with an observed the following: Facility is in good repair indoor and outdoor. Passageways, ramps, exits are free of obstruction and debris. Living/dining room has sufficient sitting area, and fire place is covered. A linen closet was observed. Kitchen area is clean. Sharps, cleaning supplies, and medication were observed locked. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Laundry room is located in the basement and additional grooming supplies were observed. Each room (4) was observed with the required furniture, and sufficient lighting. Resident #2(R2) in room #2 was observed with bed rails and a request was not on file. Each resident bathroom (4) was observed in working condition, with grab bars and skid mats and water temperature was tested between 113.5-126.1 degrees F. which is not within the required 105-120 degrees F. All required posting was observed throughout the facility. Carbon Monoxide/ Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 1/17/24. Backyard has a sitting area and front porch provides a cover sitting area. LPA reviewed medication and files for 5 residents. Resident #5(R5) was missing a pre-placement assessment. Files for 5 staff were reviewed. Administrator certificate #6066207740 exp. date: 9/8/25. Infection control plan and Emergency Disaster plan were reviewed and were updated within the last year. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Sako Manvelyan and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 1, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff slapped resident. Facility staff yelled at resident(s). Facility staff squeezed resident's arm resulting in bruising.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Ruzanna Manukyan Caregiver and explained the reason for the visit. Adrinne Adamanian Caregiver arrived 10 minutes later. The investigation consisted of the following: LPA requested copies of staff/resident roster. LPA interviewed 2 residents and 3 staff. LPA requested copies of identification and emergency sheet for resident #3(R3). LPA attempted to interview R3’s representative over the phone. The investigation revealed the following: Regarding allegations: Facility staff slapped resident and Facility staff yelled at residents. It is alleged staff was observed yelling at resident to "shut up" and by “slapping" resident on the shoulder. . Interviews with residents revealed, 2 out of 2 residents stated staff do not yell or hit the residents. Resident stated that staff are nice when providing care. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with staff revealed staff do not yell or hit the residents while in care. Per administrator there is a camera in the common areas and upon review of footage that would have been notice. There have not been any incidents at the facility. LPA reviewed training provided to staff, last training received on elder abuse was conducted on 8/11/23. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff squeezed resident's arm resulting in bruising. It is alleged staff was observed "squeezing" R3’s arm during the same incident, leaving a "black and blue" mark afterwards. Interview with residents revealed, 2 out of 2 residents stated staff have not left bruises in their bodies after assisting with care and staff “are really nice” when providing care. Interviews with staff revealed 3 out of 3 staff stated that staff provide care to residents in a respectful manner. LPA attempted to interview R3’s representative, however, was not able to obtain information regarding the allegations. LPA reviewed training provided to staff, last training on Promoting resident dignity, independence, individuality, privacy and choice was provided on 4/12/23. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED, Exit interview was conducted with Adrine Adamian and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 28-AS-20231128133551

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit due to deficiency observed at the time of the visit. LPA met with Adrine Adamian caregiver and explained the reason for the visit. On 12/5/23 LPA Flores was allowed entry to the facility by staff #1(S1), who was providing care and supervision to the residents in care. S1 stated to be working at the facility since 12/2/23. LPA Flores noticed S1 is not associated to the facility. Administrator stated that fingerprint for background clearance had been submitted to the department. LPA contacted the department to check if S1 has a background check and S1 was not found in the system. Deficiencies are noted on LIC 809D per Title 22 Regulations and Immediate Civil Penalties in the amount of $400.00 are being issued at this time. Exit interview was conducted with Adrine Adamian and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Dec 6, 2023

87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidence by: Based on observation, interviews, and documents review S1 has been working at the facility since 12/2/23 without a background clearance which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Administrator asked staff to leave and staff will return once background clearance is verify. Administrator will certify in writting to the department that will ensure all staff are cleared before starting to work.