My Lovely House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 09:29 AM. LPA met with staff #1 (S1) who contacted the facility Administrator Emma Avetisyan and the facility Designee Meri Tarposhyan. The Designee arrived to the facility at 10:26 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:35 AM the LPA, along with S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured cabinet which contained resident medications, knives, and other sharp objects. LPA observed the kitchen to contain the facility’s washer and dryer. BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy resident rooms, one (1) is a single occupancy resident room, and one (1) is a staff room. LPA and S1 toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contained a direct exit to the outdoors of the facility. LPA observed one (1) resident bed to contain full bed rails. CONTINUED ON LIC 809C. COMMON AREAS: This included the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television and activities for resident use. LPA observed a secured cabinet which contained resident and facility files. LPA observed the hallway to be clean and free from obstructions. The dining area was observed to be equipped with adequate seating for resident use. LPA observed a fire extinguisher mounted on the wall of the dining room that was purchased on 06/29/2026. All furniture throughout the facility was observed to be clean and in good repair. LPA observed the entryway to contain required postings but observed the required PUB 475 poster to be missing from the facility. The facility’s combination fire and carbon monoxide alarms were tested at 10:22 AM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BATHROOMS: There is one (1) bathroom at the facility. It is designated as a shared/common resident bathroom. The resident bathroom was observed to be clean and was equipped with nonskid surfaces. Grab bars were observed in the resident shower and near the resident toilet. All were properly secured. The bathroom contained locked storage for resident grooming supplies and cleaning supplies. The water temperature was measured to be 118.6 degrees Fahrenheit, which is within the range required by regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate seating outdoors for resident use but lacked appropriate shading. LPA observed a locked storage shed which contained cleaning and laundry chemicals. LPA observed an additional locked storage shed at the back of the property. LPA observed cameras located throughout the outdoors of the facility. RECORD REVIEW: Record review began at 11:01 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained all required documentation and trainings. Five (5) resident files were reviewed. One (1) resident who was observed to have full bed rails installed was not enrolled in hospice care. LPA informed the Designee that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. CONTINUED ON LIC 809C. MEDICATION REVIEW: Medication review began at 12:25 PM. Medications for three (3) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective Centrally Stored Medication and Destruction Record Sheets. LPA observed all resident files to be missing PRN medication authorizations forms. LPA informed the Designee that prior to staff assisting with the self-administration of PRN medications the resident’s physician must state in writing the resident’s ability to determine and communicate their need for a prescription or nonprescription PRN medication. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/10/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. LPA interviewed one (1) staff member, S1. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, emergency disaster plan, and current liability insurance. The Designee had to leave the facility at the time of the inspection but has designated S1 to sign this report on their behalf. This report was read to the Designee via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

The state marks this report as 11 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management - deficiencies visit at the facility at 09:34 AM. LPA met with staff #1 (S1) who contacted the facility Administrator Emma Avetisyan. The Administrator stated that they are unable to come to the facility during today’s visit. The Designee Meri Tarposhyan arrived to the facility at 10:30 AM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, reviewed six (6) resident files, conducted a medication audit for three (3) residents, collected copies of pertinent documentation, and conducted interviews with the Designee and three (3) residents between 09:36 AM and approximately 03:00 PM. During the physical plant tour LPA observed an unsecured knife located in an unlocked under-sink kitchen cabinet. LPA observed unsecured cleaning chemicals located in the under-sink cabinet, on top of a cabinet in the kitchen, and in the facility bathroom. LPA informed S1 who immediately secured the items. LPA informed the Administrator and Designee that the facility was recently cited for a violation of California Code of Regulations (CCR) 87309(a) on 07/09/2025. LPA informed the Administrator and Designee that because this is a repeat violation of the same licensing regulation within a twelve-month period a civil penalty in the amount of $250 is being assessed on today’s date (05/21/2026). LPA observed an unsecured medicated ointment located in a drawer of the facility’s living room. LPA notified S1 who immediately secured the medication at the time of the visit. CONTINUED ON LIC 809C. LPA observed the sliding door in the facility’s living room to be blocked by two large chairs. LPA notified the Administrator and Designee that all outdoor and indoor passageways and stairways shall be kept free of obstruction. The Administrator agreed to remove the chairs from in front of the exit. LPA observed three (3) resident beds to contain full bed rails. LPA interviewed the Designee and asked if the residents were currently receiving hospice care. The Designee confirmed that no residents at the facility were currently enrolled in hospice care. LPA informed the Designee and Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Administrator expressed understanding and agreed to remove the full length bed rails from the identified resident’s beds. During record review LPA observed one (1) resident file to be missing from the facility. LPA interviewed the Designee who stated that they did not have a file for the resident or any documentation available for review as the resident arrived to the facility two (2) days prior. LPA informed the Designee that prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year. Additionally, LPA informed the Designee and Administrator that prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs. LPA informed the Administrator and Designee that the facility was recently cited for a violation of CCR 87458(a) on 07/09/2025. LPA informed the Administrator and Designee that because this is a repeat violation of the same licensing regulation within a twelve-month period an additional civil penalty in the amount of $250 is being assessed on today’s date (05/21/2026). The Administrator agreed to complete a pre-admission appraisal and to obtain a medical assessment for Resident #1 (R1). During file review LPA observed Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4)’s medical assessments to contain inaccurate information about the care needs and health conditions of the clients. LPA notified the Administrator and Designee that Community Care Licensing Division (CCLD) is requesting an updated medical assessment for the identified individuals. The Administrator agreed to comply with this request. CONTINUED ON LIC 809C. During medication review LPA observed two (2) resident’s medications to not be appropriately logged on their respective Centrally Stored Medication and Destruction Record Sheets (CSMDRs). LPA notified the Designee who stated that one (1) resident’s medications came in two (2) days prior and that they were unable to log the medications due to a family emergency. The Designee was unable to provide a justification as to why the second resident’s CSMDR was missing an entry for a prescribed medication. LPA informed the Administrator and Designee that because of the errors on the CSMDRs and the previously mentioned unsecured medication that was found unsecured in the living room a citation for CCR 87465(h) is being issued today. LPA informed the Administrator and Designee that the facility was recently cited for a violation of CCR 87465(h) on 07/09/2025. LPA informed the Administrator and Designee that because this is a repeat violation of the same licensing regulation within a twelve-month period an additional civil penalty in the amount of $250 is being assessed on today’s date (05/21/2026). The Designee had to leave the facility at the time of the inspection. The Administrator has designated S1 to sign this report and the civil penalty assessments on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalties were cited/assessed (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, May 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 22, 2026

87309 Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions...knives..., and other similar items... are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as cleaning chemicals and a knife were left accessible to clients in care and were not placed in a secured storage which posed an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator agreed to conduct staff training with all facility staff including the Administrator and Designee on the importance of securing cleaning chemicals, knives, and other dangerous objects. Administrator agreed to submit proof of completed training to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h) · Plan of correction due date: May 22, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as a medication was observed to be outside of locked storage and two (2) resident's medications were not logged on their CSMDR which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator agreed to conduct staff training with all facility staff including the Administrator and Designee on the importance of securing medications and accurately logging medications. Administrator agreed to submit proof of completed training to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Jun 4, 2026

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as one (1) resident did not have a completed medical assessment prior to their acceptance to the facility which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator agreed to obtain a completed medical assessment for the identified individual and to submit proof of the completed medical assessment to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c) · Plan of correction due date: Jun 4, 2026

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as one (1) resident did not have a completed pre admission appraisal prior to their acceptance to the facility which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator agreed to complete a pre-admission appraisal for the identified individual and to submit proof of the completed appraisal to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Jun 4, 2026

87307 Personal Accommodations and Services (d) The following...shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the sliding door exit in the living room of the facility was observed to be blocked by two large chairs which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Administrator agreed to remove the chairs from in front of the exit and to provide proof of a clear exit in the living room to CCLD no later than POC due date.

Allegation investigated: Facility Staff did not safeguard a resident's personal belongings

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:30 AM. LPA met with staff #1 (S1) who contacted the facility Designee Meri Tarposhyan. The Designee arrived to the facility at 10:18 AM. Entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, collected copies of pertinant documentation, conducted interviews with the Designee, one (1) staff member, one (1) witness, and two (2) residents between 10:15 AM and 01:00 PM. Continued on LIC 9099C. Substantiated The allegation of “Facility Staff did not safeguard a resident's personal belongings.” alleges that resident #1 (R1)’s two (2) pairs of Levi jeans, five (5) long sleeved shirts, two (2) robes, and a pair of black Velcro sneakers that they arrived to the facility with are now missing. Additionally, the allegation alleges that a suede jacket was washed improperly and ruined by facility staff. LPA reviewed R1’s file and reviewed their signed personal property and valuables sheet. LPA observed this sheet to be signed by both Resident #1 (R1) and the facility Administrator. LPA observed this sheet to indicate that R1 arrived to the facility with two (2) pants, nine (9) t-shirts, three (3) outerwear, two (2) underwear, and six (6) socks. LPA did not observe the property and valuables sheet to contain robes, long sleeved shirts, or sneakers. LPA observed R1’s closet and observed eight (8) t-shirts. Additionally, LPA observed R1 wearing one (1) t-shirt. LPA did not observe any additional clothing items in R1’s closet. LPA interviewed the Administrator, the Designee, and S1. All three (3) staff interviewed did not know where the outerwear, underwear, or socks were located. The Administrator confirmed that the two pairs of jeans were rendered unwearable following accidents and were subsequently discarded. The Administrator and Designee stated that they are in the process of replacing the pants and they should be arriving Sunday (07/27/2025). LPA interviewed Witness #1 (W1) who stated that they were in control of R1’s suede jacket. W1 confirmed that the jacket never resided at the facility and was not ruined in the laundry. During today's visit LPA was provided with copies of receipts showing the order of two (2) pairs of Levi Jeans and men's boxers tare o be delivered Sunday (07/27/2025). Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Facility Staff did not safeguard a resident's personal belongings.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). This report was read to the Administrator via telephone call. A copy of the report was printed, appeal rights were provided, and exit interview was conducted. The allegation of “The facility telephone is inoperable” alleges that the facility does not have a working telephone for resident use. LPA conducted a physical plant tour and observed an iPhone that is designated as the facility’s telephone for resident use. LPA observed the telephone to be charged and the telephone appeared functional. LPA made a call to the telephone and confirmed proper function of the device. LPA interviewed S1. S1 was knowledgeable on the resident’s rights and confirmed that they were aware of the resident’s rights to utilize the facility telephone. S1 stated that if calls are received on the phone they will hand the telephone to the resident and provide them privacy while they speak. LPA interviewed the Administrator who confirmed that the facility telephone is always present at the facility and is available for resident use upon request. During today’s visit LPA observed resident #1 (R1) to request to use the facility phone. LPA observed S1 immediately providing the phone to R1 for use. Resident #2 (R2) was interviewed and had no concerns about access to the facility phone. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “The facility telephone is inoperable.” Therefore, the allegation is deemed Unsubstantiated at this time. This report was read to the Administrator via telephone call. A copy of the report was printed, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 29-AS-20250721113124

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153 · Plan of correction due date: Aug 7, 2025

§1569.153 Theft and loss program... ...The program shall include... (d)...Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility... This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as 3 outerwear, 6 socks, and 2 underwear were not at the facility and were not listed as removed from the resident's property list which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Administrator provided proof that they have ordered the missing pants and underwear. Designee agreed to submit a statement of understanding confirming that they understand the importance of safeguarding personal property and valuables and the importance of logging removed items. Designee agreed to submit the statement of understanding no later than POC due date.

Allegation investigated: Residents who are bedridden are being retained in a room without bedridden fire clearance

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:59 AM. LPA met with staff #1 (S1) who contacted the facility Administrator Emma Avetisyan. The Administrator stated that they are unable to come to the facility during today’s visit but has designated S1 to sign this report on their behalf. Entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, reviewed three (3) resident files, and conducted interviews with the Administrator, one (1) staff member, one (1) witness, and two (2) residents between 10:05 AM and 03:00 PM. Continued on LIC-9099C Substantiated The allegation of “Residents who are bedridden are being retained in a room without bedridden fire clearance” alleges that the facility is retaining two (2) bedridden individuals in a non-bedridden approved room in violation of their fire clearance. LPA identified resident #1 (R1), and resident #2 (R2) as the subjects of the complaint. LPA conducted a physical plant tour and observed R1 and R2’s room. R2 was not present at the facility during the inspection. During the interview with S1 they confirmed that they do assist R1 and R2 with repositioning in bed. S1 stated that they assist R1 and R2 approximately every two (2) hours. S1 stated that R2 was able to reposition without assistance until approximately two (2) to three (3) weeks ago. LPA interviewed R1 who confirmed that they require assistance with repositioning in bed. During the interview R1 demonstrated the inability to reposition without assistance. Additionally, R1 stated that they and R2 are roommates. R1 confirmed that R2 requires and is being provided with assistance in repositioning in bed. LPA reviewed R1 and R2’s resident files. R1’s medical assessment dated 10/15/2024 identifies them as “non-ambulatory” and R2’s medical assessment dated 07/09/2025 identifies them as “non-ambulatory”. LPA interviewed Witness #1 (W1) who confirmed that their criteria for determining if a resident is “Non-Ambulatory” Vs. “Bedridden” includes determining the resident’s ability to reposition themselves in bed without assistance. W1 confirmed that R1 is no longer a client of their office. LPA interviewed the facility Administrator who confirmed that R1 is “Mostly” bedridden and receives assistance from staff with repositioning. The Administrator stated that R2 began needing assistance with repositioning around 07/10/2025 before their hospitalization on 07/12/2025. LPA reviewed the facility’s fire clearance and observed that the facility is cleared to retain one (1) bedridden resident in bedroom #3 only. LPA observed both R1 and R2 to reside in bedroom #1 which is only cleared for non-ambulatory residents. LPA informed the Administrator that retaining bedridden residents in a room which is designated as non-ambulatory is a violation of their fire clearance and an immediate civil penalty in the amount of $500 is being assessed on today’s date (07/21/2025). LPA informed the Administrator that per their approved fire clearance they may only retain one (1) bedridden resident and failure to relocate the bedridden resident to the bedridden approved room may result in the issuance of a 100$/day civil penalty. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Residents who are bedridden are being retained in a room without bedridden fire clearance.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency and civil penalty were cited (refer to LIC 9099D). This report was read to the Administrator via telephone call. A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 29-AS-20250714162452

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.149 · Plan of correction due date: Jul 22, 2025

§1569.149 Fire clearance... ...the facility shall secure and maintain a fire clearance approval from the local fire enforcing agency, as defined in Section 13244, or the State Fire Marshal... This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee did not comply with the section cited above as R1 and R2 need assistance with repositioning in bed and did not reside in the bedridden approved room which poses an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, Jul 21, 2025

Plan of correction: The Administrator agreed to notify the local fire department of the bedridden residents residing in the non-ambulatory room. The Administrator agreed to move one resident to the bedridden approved room. The Administrator understood that the facility is approved for one bedridden resident only.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:59 AM to conduct an unannounced Case Management visit at the facility today. LPA met with staff #1 (S1) who contacted the facility Administrator Emma Avetisyan. The Administrator stated that they are unable to come to the facility during today’s visit but has designated S1 to sign this report on their behalf. Entrance interview was conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, reviewed three (3) resident files, and conducted interviews with the Administrator, one (1) staff member, one (1) witness, and two (2) residents between 10:05 AM and 03:00 PM. During interviews and file review LPA observed Resident #1 (R1) and resident #2 (R2)’s files. LPA observed both R1 and R2 to be identified on their medical assessments as “non-ambulatory”. Interviews with the Administrator, S1, and R1 revealed that both R1 and R2 are unable to reposition in bed without the assistance of staff. LPA informed the Administrator that this is a change in condition of the residents and an updated medical assessment is required. LPA informed the Administrator that they were recently cited during the required annual visit on 07/09/2025 for a violation of CCR 87463(f). LPA informed the Administrator that this is a repeat violation of the same regulation within a twelve (12) month period. LPA informed the Administrator that a civil penalty in the amount of $250 is being assessed on today’s date (07/21/2025) for a repeat violation. ` Continued on LIC 809C. During interviews with S1 and the Administrator LPA was informed of the recent hospitalization of R2 on 07/12/2025. LPA reviewed the facility’s file for submitted incident reports and did not observe a report submitted for R2. LPA informed the Administrator who confirmed that they are aware that reports must be submitted to the licensing agency and the resident’s responsible party no later than seven (7) days following the occurrence of the incident. LPA informed the Administrator that they were recently cited for a violation of CCR 87211(a)(1) on 04/29/2025. LPA informed the Administrator that this is a repeat violation of the same regulation within a twelve (12) month period. LPA informed the Administrator that a civil penalty in the amount of $250 is being assessed on today’s date (07/21/2025) for a repeat violation. The following deficiencies and civil penalties were cited (refer to LIC 9099D). This report was read to the Administrator via telephone call. A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(f) · Plan of correction due date: Aug 4, 2025

(f) The licensee shall immediately, or as soon as reasonably possible, communicate...the recommendation...of the appropriate licensed medical professiona...Documentation...shall be added to the resident’s record.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above asR1 and R2 did not have an updated medical assessment that accurately reflected their current conditions following a change in condition which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2025

Plan of correction: Administrator agreed to obtain updated medical assessments for the identified individuals and send proof of the completed medical assessment no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Aug 4, 2025

87211 Reporting Requirements (a) Each licensee shall... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days... This requirement is not met as eviednced by: Based on interviews and record review the licensee did not comply with the section cited above as R2's recent hospitalization was not reported to CCLD within the required timeframe which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 21, 2025

Plan of correction: Administrator agreed to submit the incident report to licensing no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:16 AM. LPA met with staff #1 (S1) who contacted the facility Administrator Emma Avetisyan. The Administrator arrived to the facility at 12:25 PM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:20 AM the LPA, along with S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed the dry food storage cabinet to contain one jar of opened and expired hot pepper sauce. LPA informed the Administrator who discarded the jar during the visit and agreed to conduct an audit of the facility’s food supplies. LPA observed a secured cabinet to contain resident medications, knives, and other sharp objects. LPA observed the kitchen to contain the facility’s washer and dryer. LPA observed a camera in the kitchen that appeared disabled with the lens covered. Continued on LIC 809C. COMMON AREAS: This includes the living room and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television and activities for resident use. LPA observed the living room to contain an cabinet located under the television. LPA observed a secured section of this cabinet to contain resident and facility files. LPA observed an unsecured drawer in this cabinet to contain Monday-Sunday pill organizers filled with medications accessible to clients in care. LPA informed the Administrator who secured the medications at the time of the visit. The dining area was observed to be equipped with adequate seating for resident use. LPA observed a fire extinguisher mounted on the wall of the dining room to be purchased on 06/26/2025. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:11 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy resident rooms, one (1) is a single occupancy resident room, and one (1) is a staff room. LPA toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contained a direct exit to the outdoors of the facility. BATHROOMS: There is one (1) bathroom at the facility. It is designated as a shared/common resident bathroom. The resident bathroom was observed to be clean and was equipped with nonskid surfaces. Grab bars were observed in the resident shower and near the resident toilet. The water temperature was measured to be 113.5 degrees Fahrenheit, which is within the range required by regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed an unlocked storage shed that contained tools, saw blades, paints, and pesticides. LPA informed the Administrator who secured the shed during the visit. Continued on LIC 809C. RECORD REVIEW: Record review began at 11:25 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. One (1) staff member, staff #2 (S2) was observed to have fingerprint clearance but was not associated to the facility. LPA informed the Administrator that employees must obtain a fingerprint clearance and be associated to the facility prior to working, residing or volunteering in a licensed facility. LPA informed the Administrator that a civil penalty in the amount of 500$ (1 Employee x 100$/day x 5 days [maximum of 5 days] = $500) will be assessed on today’s date (07/09/2025) for not having submitted a criminal record clearance transfer request for S2. All other staff files contained all required documents and trainings. Five (5) resident files were reviewed. Resident #1 (R1)’s medical assessment was observed to contain inaccurate information after a change in condition. LPA did not observe a reappraisal in R1’s file. LPA informed the Administrator who agreed to obtain an updated medical assessment for R1 which accurately reflects R1’s current condition. Resident #2 (R2)’s medical assessment was observed to be dated 11/03/2023 and R2 was admitted to the facility on 01/27/2025. LPA informed the Administrator that prior to a person's acceptance as a resident, they shall obtain documentation of a medical assessment made within the last year. The Administrator expressed understanding and agreed to obtain an updated medical assessment for R2. All other resident files contained all required documentation and signatures. MEDICATION REVIEW: Medication review began at 12:25 PM. Medications for two (2) of five (5) residents were observed. Resident #3 (R3)’s medications were observed to have the incorrect prescription numbers documented on their centrally stored medication and destruction record sheet (CSMDR). LPA informed the Administrator who agreed to conduct an audit of the resident’s CSMDR’s to ensure accurate information. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/18/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. Continued on LIC 809C. INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. LPA interviewed one (1) staff member, S1. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. The Administrator had to leave the facility at the time of the inspection but has designated staff #2 (S2) to sign this report on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

The state marks this report as 12 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not report incidents to resident's responsible person

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:29 AM. LPA met with facility staff who contacted the facility Designee Hripsime “Ripa” Tavitian. The Designee arrived to the facility at 10:10 AM the reason for the visit was explained and entrance interview was conducted. LPA and the Designee contacted the Administrator Emma Avetisyan via telephone call. The Administrator was unable to come to the facility at the time of the inspection but has designated the Designee to sign this report on their behalf. During today’s visit LPA conducted a physical plant tour, reviewed five (5) resident files, and interviewed the Designee, the Administrator, one (1) staff and four (4) residents between 10:12 AM and 03:00 PM. Continued on LIC-9099C Substantiated The allegation of “Facility staff did not report incidents to resident's responsible person” alleges that the facility did not notify the responsible party of Resident #1 (R1) of falls that R1 experienced while in the care of the facility. During interviews with residents of the facility Resident #2 (R2) stated that they experienced a fall at the facility about one month ago. Additionally, R2 stated that they suffered an incident where a table that was leaned up against a wall of the facility slipped and hit their ankle. LPA interviewed Staff #1 (S1) who remembered both of the incidents involving R2. S1 also recalled R1 experiencing a fall while at the facility. S1 stated that R1 attempted to walk without staff assistance and fell forward hitting their face on the ground. S1 stated that R1 experienced a cut on their upper lip and a scratch on their neck. S1 stated that for both R1’s and R2’s falls they notified the Administrator of the incidents. LPA reviewed the facility’s E-Folder for incident reports. LPA observed the incident folder to be empty and confirmed that no incident reports were pending review in their folder. LPA informed the Designee who stated that they were unaware of any falls occurring at the facility. LPA interviewed the Administrator who confirmed that they were aware of three (3) falls that occurred at the facility. LPA asked the Administrator if incident reports were submitted for the falls and the Administrator confirmed that they were not. The Administrator confirmed that they would submit reports for all resident incidents in the future. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Facility staff did not report incidents to resident's responsible person.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). This report was read to the Administrator via telephone call. A copy of the report was printed, appeal rights were provided, and exit interview was conducted. The allegation of “Facility staff did not assist resident with medical appointments” alleges that the facility did not assist R1 with doctor’s appointments and testing. Interviews with current residents of the facility did not reveal any concerns with residents receiving medical care or assistance in arranging appointments. Interviews with S1 revealed that they were never made aware of R1 requiring assistance in arranging or transport to medical appointments or testing. During the interview with the Designee they stated that R1 was a resident of the facility for such a short time and denied the responsible party of R1 ever making the facility aware of needed testing’s or appointments. The Designee stated that appointments for residents are conducted with physicians either in person or over Facetime. Additionally, the Designee revealed that the facility has contact with a mobile doctor that can evaluate residents if needed. LPA interviewed the Administrator who denied R1's representatives ever informing them of a doctor's appointment or test for R1. The Administrator confirmed that R1 resided at the facility from 03/24/2025-04/09/2025. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Facility staff did not assist resident with medical appointments.” Therefore, the allegation is deemed Unsubstantiated at this time. This report was read to the Administrator via telephone call. A copy of the report was printed, and exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 29-AS-20250409100933

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 29, 2025

87211 Reporting Requirements (a) Each licensee shall... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days... This requirement is not met as eviednced by: Based on interviews and record review the licensee did not comply with the section cited above as residents experienced three falls at the facility which were not reported to the resident's responsible parties or CCLD which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: Licensee will subimt a statement of understanding confirming that they understand the improtance of timely reporting to CCLD no later than POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management - deficiencies visit at the facility at 09:29 AM. LPA met with facility staff who contacted the facility Designee Hripsime “Ripa” Tavitian. The Designee arrived to the facility at 10:10 AM the reason for the visit was explained and entrance interview was conducted. LPA and the Designee contacted the Administrator Nona Ohanyan via telephone call. The Administrator was unable to come to the facility at the time of the inspection but has designated the designee to sign this report on their behalf. During today’s visit LPA conducted a physical plant tour, reviewed five (5) resident files, and interviewed the Designee, one (1) staff and four (4) residents between 10:12 AM and 03:00 PM. During file review LPA observed two (2) resident's admission agreements to be missing information. Both admission agreements were missing the rates residents were being charged for basic services. One (1) admission agreement was observed to be missing initials and signatures on all but the last page of the document. LPA reviewed the facility personnel summary for all individuals associated and cleared to work for the facility. While reviewing this list LPA did not observe Staff #1 (S1) to be associated to the facility. S1 was observed to be working during the visit and was providing care and supervision to the residents. During an interview with S1 they revealed that they have worked for the facility for approximately 2 months. Continued on LIC 809C. LPA informed the Administrator that having un-associated individuals providing care and supervision poses an immediate health, safety, or personal rights risk to clients in care. LPA informed the Administrator that a civil penalty in the amount of $100 per day S1 has been working, up to a maximum of five (5) days, will be assessed for a total of $500. LPA informed that Administrator that the civil penalty will be assessed on today’s date (04/15/2025). The Administrator expressed understanding and confirmed that S1 would be associated to the facility before the plan of correction due date. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Apr 16, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as S1 is not associated to the facility on Guardian or LIS which poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: Licensee will submit proof of S1's association to the facility no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(g)(3)(A) · Plan of correction due date: Apr 29, 2025

87507 Admission Agreements (g) Admission agreements shall specify the following: (3) Payment provisions, including... (A) Rate for all basic services... This requirement is not met as eviednced by: Based on record review the licensee did not comply with the section cited above as two residents had incomplete admission agreements that were missing the amount charged for basic services which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: Licensee will submit proof of two completed admission agreements for the identified residents no later than POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sandra Urena conducted a follow up Pre-licensing visit to the facility. LPA met with applicant Nona Ohanyan. Entrance interview conducted. This is a Change of Ownership(CHOW) application for five (5) residents. A Hospice Waiver for five (5) residents has been granted. The LPA, and the applicant 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. On 05/23/2024, LPA Urena conducted an initial visit, and corrections were needed during the visit. Administrator agreed to do the following corrections. · Change bed from room #2 to room #3, which is the approved room for a bedridden resident. -Corrected · Reorganize closest for rooms # 1 and 2.-Corrected · Cell phone specifically for residents’ use.-Corrected · Gardening supplies will be cleared and locked in the shed.- Corrected · Facility sketch will be updated to reflect the approved fire department sketch.-Corrected This report will be sent to the Centralized Application Unit (CAB) once all corrections are received. You will be notified by the CAU 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 a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 1, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sandra Urena conducted an announced Pre-licensing visit to the facility. LPA met with applicant Nona Ohanyan. Entrance interview conducted. This is a Change of Ownership(CHOW) application for six (6) residents. A Hospice Waiver for six (6) residents has been granted. At 9:45 a.m., the LPA, and the applicant 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. Facility is a single-story residence, which consists of three (3) bedrooms and one (1) bathroom. Fire Clearance was approved on 02/15/2024 for five (5) non ambulatory and one (1) bedridden resident to reside in bedroom #3. At the time of the visit, the LPA observed the facility sketch to be different than the one submitted to the Centralized Application Branch (CAB). Per the applicant an updated sketch approved by the fire department was emailed to CAB. However at the time LPA Urena received the pre-application packet, the original facility sketch was received with the packet. with the packet. The LPA will contact CAB about an updated facility sketch and a new approved fire clearance before completing the prelicencing visit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Smoke detectors and Carbon monoxide detector are hard wired throughout the facility. Fire extinguisher was observed to be fully charged and purchased 12/11/2023. Facility accept dementia residents. The LPA observed signal alarms on exit doors. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of non-perishable food at the facility; properly stored. Sharp objects will be stored in a top kitchen cabinet. Medication will be locked in cabinet in the living room area. A laundry area with a washer and dryer was observed in a corner of the kitchen area. Conitnues on LIC 809C... Bedrooms: The resident 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. Bathrooms: LPA observed one bathroom to be clean, properly supplied and had functional fixtures. LPA observed the bathroom to have grab bars and non-skid mats. The hot water measured at 117.8 degrees Fahrenheit during visit. Surrounding Grounds (Outdoors): LPA observed a shaded area outdoors for resident use. Appropriate outdoor furniture was present during the inspection. There are no bodies of water on the premises. There is a detached shed in the corner of the facility for storage purposes. The applicant stated they will keep door locked at all times. Administrator agreed to send corrections to LPA by 05/29/2024. · Change bed with adaptable rails from room #2 to room #3, which is the approved room for a bedridden resident. · Reorganize closest for rooms # 1 and 2. · Cell phone specifically for residents’ use. · Facility sketch will be updated to reflect the approved fire department sketch. · Gardening supplies will be cleared and locked in the shed. The applicant completed Component III Orientation. This report will be sent to the Centralized Application Unit (CAU) once all corrections are received. You will be notified by the CAU 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 CAU Analyst. Failure to comply could affect approval of your license. Exit interview conducted/Copy of this report giventhe state’s words, verbatim · CDSS document, May 23, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 6 Census (if any clients in care): Unknown COMP II Participants: Nona Ohanyan, Armine Grigoryan Interview Method: Telephone interview On March 06, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 6, 2024