Nazareth House

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Janet Ngallo conducted a case management incident visit regarding a self-reported incident involving staff member (S1) and the theft of a resident’s personal property. The licensee reported that the incident came to light after R1's representative discovered unauthorized charges on R1's credit card. The licensee stated that after learning of the issue, S1 admitted taking R1's belongings, was terminated from employment, and appropriate agencies were notified. Interviews with staff confirmed that the incident occurred. Records review revealed that the facility’s theft/loss policy requires documentation of lost or stolen property and notification to appropriate agencies, and states that employees are prohibited from accepting gratuities. Records review revealed the facility filed a police report and incident report received by the department. A review of staff meeting records confirmed that a meeting was held regarding the theft. Employee records confirmed that S1 was terminated on 05/01/2026 for violating company policies. Based on interviews and records review, the incident that occurred was determined to be a violation of California Code of Regulations, Title 22. A deficiency is cited (refer to the attached LIC 9099-D) and a plan of Correction was jointly developed with the licensee. An exit interview was conducted with CEO BarbaraAnne Crowley, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: May 15, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition ...residents… shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code sections 1569.152,1569.153, and 1569.154. This requirement was not met as evidenced by: Based on record review and interview, a staff member (S1) took a resident’s credit card and cash valued at $884.04. This posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: Per the licensee and the Department's investigation licensee terminated S1 on May 1st, 2026. Deficiency is cleared as of today's visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with CEO BarbaraAnne Crowley. According to the facility’s license, the facility has a maximum capacity of 145 residents, of whom all may be non-ambulatory. During today’s inspection, there were a total of ninety-three (93) residents in care. This facility does not feature a secured perimeter or delayed egress doors. LPA Ngallo, accompanied by Barbara Anne Crowley, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant. The facility's kitchen area is currently undergoing remodeling and construction. CEO BarbaraAnne Crowley informed the LPA that a temporary off-site kitchen is being utilized during this period, and all meals are being prepared and delivered to the facility from that location. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per BarbaraAnne Crowley, no firearms or ammunition are kept at the facility. (Cont. on LIC 809-C page) (Cont. from LIC 809) Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. An exit interview was conducted with CEO BarbaraAnne Crowley, to whom a copy of this report and Licensee Rights (LIC 9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jan 2, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Facilities Nayana Goonatilaka and Executive Director Milena Petrosyan. According to the facility’s license, the facility has a maximum capacity of 145 residents, of whom all may be non-ambulatory. During today’s inspection, there were a total of ninety-two (92) clients in care. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by Milena Petrosyan, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Milena Petrosyan, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. Milena Petrosyan also presented proof of current/active business liability insurance. An exit interview was conducted with Milena Petrosyan and Nayana Goonatilaka, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Milena Petrosyan and Nayana Goonatilaka.the state’s words, verbatim · CDSS document, Jan 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced visit for a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Facilities Nayana Goonatilaka. LPA was then joined by Director Milena Petrosyan. During today’s visit, LPA toured the facility with Milena Petrosyan and Nayana Goonatilaka, interviewed residents and staff, and reviewed records. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with Milena Petrosyan and Nayana Goonatilaka, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Milena Petrosyan and Nayana Goonatilaka.the state’s words, verbatim · CDSS document, Jan 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Executive Director Milena Petrosyan, and Chief Executive Officer Barbara Crowley after identifying herself and stating the purpose of the inspection. Facility is licensed one Hundred Forty Five residents, ages 60 and above, all of whom may be non-ambulatory. Hospice waiver is approved for fifteen residents. LPA was accompanied by Executive Director Petrosyan, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas. There is a fire system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted in January 2024 and conducted quarterly. Exterior and interior passageways were free from obstructions. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. No pools or bodies of water were observed on the premises. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with the required furnishings and appropriate lighting to ensure the comfort and safety of residents. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and non-skid strips are present in the showers. Resident’s room temperatures were within a comfortable range. Hot water temperature at taps accessible to clients were all compliant. Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. [Continued on 809-C] [Continued on 809] LPA observed an operational signal system. Medications are locked in carts, not accessible to residents. Carts are kept in the medication room. Medications were labeled and kept in compliance with label instructions. LPA interview with staff indicates the facility arranges or assists in arranging medical and dental care appropriate to the conditions and needs of residents. This includes assisting in arranging transportation for incidental medical and dental appointments. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. There are several areas used for activities such as: daily music, exercises, arts/crafts, and chapel services. At the time of visit, LPA observed a small group activity, in which some residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet residents’ needs. Based on today’s inspection, no deficiencies were observed in the areas evaluated. An exit interview was conducted with Executive Director Petrosyan and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to Executive Director Petrosyan, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 31, 2024