My Home of Aging

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:17AM. Upon arrival, LPA met with staff and House Manager Farnaz Servati and Administrator Vishtasb Kykhosrowpour who arrived during the visit. Entrance interview conducted. At 11:31AM, the LPA along with the House Manager, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: LPA inspected the kitchen/food service area at 11:31AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives and chemicals were locked inaccessible in kitchen drawer and under-the-sink cabinet. BEDROOMS: There are six (6) private resident bedrooms. Bedroom #1 has a direct exit to the exterior. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are four (4) restrooms designated for resident-use of which two (2) restrooms are attached to resident bedrooms and two (2) are located in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperature was measured in client bathrooms and were between 106.5-110.1 degrees F, which is within the required range. Report Continued on LIC 809-C. COMMON AREAS: The common spaces included the living room, dining area, and office area. LPA observed cameras in all common spaces and exterior without an audio component. All areas were clean, sanitary and in good repair. The facility smoke alarm system is hard wired; the combination smoke and carbon monoxide detectors were tested at 11:53AM and were operable at the time of the visit. The fire extinguisher was observed be fully charged and last purchased 05/08/2026. Auditory exit alarms were tested and functional at the time of the visit. LPA observed required postings in the entrance hallway. OUTDOOR AREA/GARAGE: The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool on the property that was observed to be gated and locked at the time of the visit. There is a self-latching gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. LPA observed a laundry room which is located inside the attached garage. Laundry detergents, additional refrigerator/freezer, cleaning supplies, pesticides, and/or toxins are also stored in the garage/laundry area. RECORD REVIEW: Beginning at 12:06PM, LPA reviewed six (6) out of six (6) resident files and five (5) out of five (5) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. Two (2) out of six (6) residents were missing a reappraisal within the last 12 months. Staff #1 (S1) was missing a transfer of criminal record clearance. MEDICATION REVIEW: At 02:51PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in the garage. All medications were labeled, stored, and locked inaccessible to residents. Medications are properly documented on the centrally stored medications and destruction record. Two (2) over-the-counter medications for Resident #1 (R1) were missing physician’s orders on file. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly, with the last drill on 05/10/2026. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty was issued in the amount of $500 for criminal record clearance. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 20, 2026

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 09:56AM. Upon arrival, LPA met with staff and House Manager Farnaz Servati who arrived at 10:02AM and Administrator Vishtasb Kykhosrowpour who arrived at 10:17AM. Entrance interview conducted. At 10:03AM, the LPA along with the House Manager, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 10:03AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives and chemicals were locked inaccessible in kitchen drawer and under-the-sink cabinet. BEDROOMS: There are six (6) private resident bedrooms. Bedroom #1 has a direct exit to the exterior. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are four (4) restrooms designated for resident-use of which two (2) restrooms are attached to resident bedrooms and two (2) are located in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The restrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Hot water temperature was measured in three (3) bathrooms and measured between 115.4-119.2 degrees Fahrenheit, which is within the required range. Report Continued on LIC 809-C COMMON AREAS: The common spaces included the living room, dining area, and office area. LPA observed cameras in all common spaces and exterior without an audio component. All areas were clean, sanitary and in good repair. The facility smoke alarm system is hard wired; the combination smoke and carbon monoxide detectors were tested at 10:19AM and were operable at the time of the visit. The fire extinguisher was observed be fully charged and last purchased 04/25/2025. Auditory exit alarms were tested and functional at the time of the visit. LPA observed required postings in the entrance hallway. OUTDOOR AREA/GARAGE: The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool on the property that was observed to be gated and locked at the time of the visit. There is a self-latching gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. LPA observed a laundry room which is located inside the attached garage. Laundry detergents, additional refrigerator/freezer, cleaning supplies, pesticides, and/or toxins are also stored in the garage/laundry area. RECORD REVIEW: Beginning at 10:38AM, LPA reviewed five (5) out of five (5) resident files and four (4) out of four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. All resident files were in order. One (1) out of four (4) staff was missing first aid training; training was completed during the visit. MEDICATION REVIEW: At 02:20PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in the garage. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order and authorization letter on file. Medications are properly documented on the centrally stored medications and destruction record. One (1) medication of Metoprolol was expired on 04/28/2025. House Manager will destroy the medication. No errors observed during the medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 03/26/2025. All documents reviewed were updated and in compliance. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 1, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochain arrived at the facility unannounced to conduct a required Annual visit. LPA met with Administrator and Farnaz Servati and explained the reason for the visit. The LPA toured the physical plant areas inside and outside, with Administrator at 4pm., to ensure there are no health and safety hazards. BEDROOMS: There are (6) six bedrooms designated for resident use. Bedroom #1 has a direct exit to the exterior. The bedrooms are furnishing with clean linens, appropriate furnishings, and sufficient lighting for resident use. RESTROOMS: There are (4) four bathrooms designated for residents use. (2) two bathrooms are located inside the resident bedrooms and (2) two are located in the hallway. Bathrooms observed clean, sanitary, and in operating condition with grab bars and non-skid surfaces. Cleaning supplies observed in the restroom located in the hallway at approximately 4:35pm. Licensee/Administrator removed the four clean solution bottles and locked it in the garage during visit. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. COMMON SPACES: The common spaces included the living room; dining area and office area. The LPA observed cameras in all common spaces and exterior. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. The fire extinguisher was observed to be in compliance within one year. The LPA observed required postings in the entrance hallway. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool on the property that was observed to be gated and locked at the time of the visit. The LPA observed a Laundry room which is located inside the attached garage. Laundry detergents, cleaning supplies, pesticides, and/or toxins are also stored in the garage/laundry area. Due to time constraints, the annual inspection will be completed on a follow-up visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview held. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, May 29, 2024