No Place Like Home for Golden Ages 2

Type of visit: Required - 1 Year

On 07/07/26, at 10:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with Emma Topadzuikyan, the administrator. LPA asked for the census, resident, and staff files. There is one (1) entrance being utilized at the facility. The facility has a total of three (03) resident bedrooms and three 1/2 (3 and 1/2) bathrooms. Outside/Backyard: The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool/body of water that is locked and inaccessible to the residents. There is a detached garage used as storage. There is also one (1) washer and dryer. Kitchen area: Kitchen is sufficiently stocked with at least seven (07) days perishable and seven (07) days non-perishable food. There is one (1) refrigerator with frozen foods wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps were locked and inaccessible to residents in one (1) of the bottom cabinets in the kitchen. There is one (1) additional freezer in the kitchen area. LIC 809C continued No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector were tested and operational. They are hardwired. Living Room and Dining Room: The living and dining room are neat and clean. The facility maintains a comfortable temperature at 78°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. The medication is locked and inaccessible to the residents in a black cabinet. Fire extinguisher is fully charged and last purchased 07/2026. Bedrooms: Facility has three (3) bedrooms and were toured. The bedrooms are fully furnished with proper lighting and bedding. Two (2) are currently shared and the other one (1) is single, occupied. Bathrooms: There are three (3) full bathrooms. The bathrooms contained a trash can with tight-fitting lid. Three (3) of the bathrooms are in the resident's room and the 1/2 bathroom is in the hallway. The hot waters were tested and measured around 115.2 and 116.8 within regulations. Administrative: The administrative Certification is current and expires 11/10/2027. The liability insurance expires on 05/01/27. There were Personal Rights, YES Sign, Ombudsman sign and Emergency Disaster Plan against the wall of the facility. The facility has cameras in common areas. Staff/Client Files: There were two (2) staff files to review at the above facility. There are four (4) resident files that were reviewed. The last fire drill was on 04/2026. An exit interview was conducted, no citation(s) were issued and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jul 7, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness. LPA met Administrator Emma Topadzuikyan and explained the reason for the visit. The current census is (5); A tour of the physical plant of the inside and outside was conducted. Kitchen: The kitchen was clean and the appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; and food was properly stored. The facility has (2,) extra refrigerators, stocked with food in the garage and backyard. Knives and detergents were stored in locked drawers and cabinets. Medication was labeled and locked in a cabinet in the living room. Bedrooms: There were (3) bedrooms; (2) shared and (1) private designated for residents. All bedrooms were properly furnished, with bedding and linens, as well as sufficient lighting. LPA observed all residents had full bed rails without proper documentation and not on hospice. Administrator will submit proper documentation to LPA. Bathroom: There were three bathrooms designated for residents. All bathrooms properly supplied with soap and towels, as well as functional fixtures; including grab bars. Hot water temperature 107.0 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets Common Areas: These included the living room and dining area: all areas were clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards, with shaded furniture for residents. Swimming pool in the backyard was secured. All smoke alarms operating properly. Fire extinguisher fully charged. Staff records: (2) staff on duty during the visit, did not have records to be reviewed, and (1) staff did not have fingerprint or association to the facility. Both staff did not have first aid/CPR certificates during visit. Resident records: Resident 1 and 2 were missing needs and service plan in there files. Resident # 3 is missing a physician report. Medication: LPA observed medication to be inaccessible and stored in a secured cabinet located in the kitchen. There were no errors observed. Citation issued, appeal rights provided, exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Aug 19, 2025

Allegation investigated: Resident sustained pressure injuries while in care

At approximately 10:45 a.m. on 05/20/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 01/03/25 and interviewed staff and residents between 1:30 p.m. and 2:45 p.m., conducted a record review of pertinent records, including but not limited to, a medical assessment and hospice documents at 2:00 p.m., and toured the facility inside and out at 1:30 p.m. Today, LPA toured the facility at 11:00 a.m. Regarding the allegation “Resident sustained pressure injuries while in care” it was alleged Resident #1 (R1) acquired a pressure injury at the facility. Record review of R1’s medical assessment revealed they had no history or signs of skin breakdown as of 11/06/24. Review of R1’s hospice documents revealed they acquired hospice services on 11/09/24 and were observed to have a Stage 1 pressure injury on their coccyx. The hospice agency provided wound treatment services. Substantiated It was noted that R1 had a loss of appetite, body weakness, and overall cognitive and physical decline. On 12/03/24, a hospice nurse observed Stage 2 injuries on R1’s coccyx and spine. On 12/18/24, a wound care agency assessed R1 to have a Stage 4 injury on their back and a Stage 3 injury on their sacrum. Both injuries were noted to be unrelated to R1’s hospice diagnosis. R1’s hospice care plan was also not updated to include the wound care and excisional debridement performed by the wound care agency. Interview with the administrator at 1:30 p.m. on 01/03/25 revealed staff were instructed to reposition R1 every two (02) hours but not to transfer them due to skin integrity issues. Interview with Staff #1 (S1) at 2:00 p.m. on 01/03/25 confirmed that all staff had been trained by the hospice agency on R1’s care. S1 repositioned R1 every two (02) hours, assisted with incontinence care, and ensured their back and coccyx were dry and free of redness. LPA was unable to interview R1. Interviews with three (03) out of three (03) other residents interviewed revealed they had no issues with pressure injuries. Interview with Resident #2 (R2) at 2:25 p.m. on 01/03/25 revealed S1 reminds them to reposition themselves often. Based on interviews and record review, although R1’s pressure injuries were appropriately cared for by R1’s hospice agency and facility staff, the facility should have applied for an exception to retain R1 in the facility while they received wound treatment unrelated to their hospice diagnosis. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided. Interview with S1 at 2:00 p.m. on 01/03/25 revealed R3 nor any other residents were tied up. S1 further stated that R3 constantly fabricated about staff abuse. Interview with the administrator confirmed R3 was not tied up and the facility had no physician orders for restraints to be used. Interviews with three (03) out of three (03) other residents interviewed revealed they had never been tied up or witnessed anyone tied up. Record review of an incident report submitted by the facility revealed R3 fell on the morning of 12/30/24 and bruised their eye. R3 had no other injuries. Based on observations, interviews, and record review, although the allegation is valid, there is insufficient evidence to verify that staff restrained a resident. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 31-AS-20241226152447

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.73(b) · Plan of correction due date: May 30, 2025

§1569.73 Terminally ill residents... (b) At any time that… the facility... determines that the resident's condition has changed ... the facility may initiate procedures for a transfer. This requirement was not met as evidenced by:This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by retaining Resident #1 (R1) with a worsening prohibited health condition and not applying for an exception which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Licensee has agreed to apply for an exception for Resident #2 (R2) who has a worsening Stage 2 pressure injury to demonstrate and establish compliance with the cited section by the POC due date.

Allegation investigated: Staff refusing to allow resident to have visitor(s). Staff does not allow resident to use the phone. Staff did not follow medication administration procedures. Staff did not provide resident with a copy of the admissions. Staff are not preventing residents from disturbing other resident Staff does not meet residents hidriation needs Food service requirments were not followed Facility has pests Staff pushed resident

At 2:00 p.m. on 01/23/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 12/20/24 and toured the facility inside and out at 10:00 a.m., interviewed staff and residents between 10:05 a.m. and 12:00 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, and hospital discharge paperwork at 11:00 a.m. LPA conducted another visit on 01/03/25 and interviewed staff and residents between 1:30 p.m. and 2:45 p.m., conducted a record review of pertinent records at 2:00 p.m., and toured the facility inside and out at 1:30 p.m. Today, LPA toured the facility at 2:00 p.m. Regarding the allegation "Staff refusing to allow resident to have visitor(s)" it was alleged Staff #1 (S1) would not allow Visitor #1 (V1) of Resident #1 (R1) into the facility. Unsubstantiated Interview with the administrator at 10:30 a.m. on 12/20/24 revealed R1 came from a rehab center. A social worker at the rehab center informed the administrator that R1 expressed they did not want to see V1. Therefore, the administrator instructed staff to ask R1 if they wanted to meet with V1 each time V1 came to the facility. Interview with R1 at 11:30 a.m. on 12/20/24 revealed they had no problem with V1. Interview with S1 at 10:15 a.m. on 12/20/24 confirmed they asked R1 if they wanted to meet with V1 and did not allow V1 in if R1 did not want to see V1. Interviews with two (02) out of three (03) other residents revealed they have no issues with visitation. Based on interviews, staff allowed residents to have visitors when they desired. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff does not allow resident to use the phone" it was alleged the facility phone was not available for R1 and may be in disrepair. LPA called the house phone at 9:50 a.m. on 12/20/24 and staff answered. The house phone was deemed operational. Interview with S1 revealed the house phone works fine, and residents use it often. Interview with R1 revealed they don’t know where their personal phone is, so they use the house phone. Two (02) out of three (03) other residents interviewed confirmed they use the house phone, and it works. Interview with the administrator revealed all residents are allowed to use the house telephone and that it is operational. LPA heard two (02) incoming calls on the house telephone during a visit on 01/03/25. Based on observations and interviews, the house telephone works and residents have no issue using it. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not follow medication administration procedures" it was alleged R1 did not receive some of their medications since refills were not picked up. Record review of R1’s medication list indicated that R1 was admitted to the facility on 08/12/24 with approximately a one month supply of medications. Interview with the administrator revealed R1 received all prescribed medications. Interview with S1 confirmed that they picked up R1’s medication refills each month from the pharmacy. Interviews with two (02) out of three (03) other residents revealed they received all medications without issues. Based on interviews and record review, the facility followed resident medication administration procedures. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not provide resident with a copy of the admissions" it was alleged R1 did not receive a copy of their admission agreement. Interview with R1 revealed they never requested a copy of the admission agreement. Interview with the administrator revealed R1 signed their admission agreement along with their representative in August 2024. The administrator noted R1 never requested a copy of the contract, and it was available in the facility. The administrator also stated that V1 requested a copy of R1’s admission agreement. Since V1 did not represent R1 and was not present for R1’s admission process, the administrator did not provide a copy of the contract to V1. Record review revealed that R1 and their representative signed R1’s admission agreement, and V1’s name or signature was not on any of R1’s documents. Based on interviews and record review, R1 never requested a copy of their admission agreement, and staff did not refuse to provide it. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are not preventing residents from disturbing other resident" it was alleged R1’s roommate, Resident #2 (R2), engaged in behaviors which disturbed R1. Interview with R1 revealed R2 does not bother them. Interviews with two (02) out of three (03) other residents revealed they get along fine with their housemates. Interview with the administrator and S1 revealed they had not seen R2 disturbing R1. The administrator did not receive any complaints from R1 about R2 either. Instead, R2 told the administrator that R1 was disturbing them at night. LPA did not observe any disturbing behavior during visits on 12/20/24, 01/03/25, or today. Based on observations and interviews, no residents are disturbing other residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff does not meet resident’s hydration needs" it was alleged R1’s water bottle cap was dirty and residents are not encouraged to drink water. Interview with the administrator revealed that all residents have water bottles which are checked hourly and filled as necessary. Staff check residents every twenty (20) minutes to encourage hydration. Interview with S1 confirmed that they provide clean water every hour and encourage residents to stay hydrated. LPA observed S1 filling resident water bottles around 1:00 p.m. on 01/03/25. Interview with R1 revealed they have no problem drinking enough water and no problem with their water bottle. LPA inspected R1’s bottle cap around 11:45 a.m. on 12/20/24. The bottle cap was clean and free from debris. Interviews with three (03) out of three (03) other residents revealed they drink enough water. Based on observations and interviews, staff meet resident hydration needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Food service requirements were not followed" it was alleged the facility food served was not nutritious. LPA observed sufficient supplies of perishable and non-perishable food during the facility tour on 12/20/24. Interview with R1 revealed they ate toast with peanut butter and jelly for breakfast on 12/20/24, but they found the food was “not too interesting” and wanted more interesting food. Interviews with three (03) out of three (03) other residents revealed they felt the facility food was fine. Interview with S1 revealed they follow R1’s vegetarian diet and served yogurt, oatmeal, and peanut butter on toast for breakfast on 12/20/24. S1 stated R1 had a good appetite and had never previously expressed problems with the food served. Interview with the administrator revealed they also had not received any complaints about the food served. Based on observations and interviews, although the allegation is valid, there was no evidence indicating the facility did not follow food service requirements. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility has pests" it was alleged a cockroach was seen in the facility. LPA did not observe any pests or signs of pests during facility tours on 12/20/24, 01/03/25, or today. Interviews with four (04) out of four (04) residents interviewed revealed they had not seen any cockroaches or other pests besides one (01) fly. Interview with Resident #3 (R3) at 2:25 p.m. on 01/03/25 revealed they see a fly sometimes, but staff take care of it “pretty quickly”. Interviews with S1 and the administrator revealed they had not seen any pests in the facility and clean often. Based on observations and interviews, although the allegation is valid, there is no evidence indicating the facility has pests. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff pushed resident" it was alleged S1 pushed R1. Interview with R1 revealed they were never pushed by S1 or any other staff. Interview with S1 revealed they nor other staff ever pushed or mistreated residents. Interviews with three (03) out of three (03) other residents interviewed revealed staff had not pushed them or handled them in a rough manner. Interview with the administrator revealed no residents had been pushed or mishandled at the facility. LPA observed staff treating residents appropriately during tours on 12/20/24, 01/03/25, and today. Based on observations and interviews, although the allegation is valid, there is no evidence suggesting staff pushed a resident. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 31-AS-20241219122415

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced annual visit. LPA met with Caregiver Estellita San Pedro and explained the reason for the visit. The facility is licensed to serve 5 non-ambulatory residents ages between 60 and over and a hospice waiver for 2 hospice residents. Facility is a one story single home in a residential area and consists of the following: 3 bedrooms, 3 resident bathrooms, 1 staff bathroom, garage, gated pool with pool house. Backyard has an area with tables/ umbrellas for shade. Facility has a living room, kitchen/dining room and front porch. Pool house is inaccessible to residents. LPA Valenzuela conducted a tour of the facility with Caregiver Estellita San Pedro and observed the following: Living room has a cover fireplace, sufficient sitting area, and signs posted. Medication cabinet is located in the living room and was observed to be locked. Knives and cleaning supplies were observed to be locked under the kitchen sink. Facility has sufficient food supplies for at least 2 days worth of perishables and 7 days of non-perishables. Residents rooms were observed as follows: Room #3 (R3) has all required furniture and bedding, Room #1(R1) and Room #2(R2) have all required furniture, bedding, and sufficient lighting. Water temperature was measured at 120 degrees F, which is not within the required 105-120 degrees F. Smoke/Carbon Monoxide detectors were observed, tested, and in working condition. Fired extinguisher was observed in the kitchen. Files were reviewed for 4 residents. Five staff files were also reviewed. There is one complete first aid kit. Continue on 9099-C No health or safety issues observed at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 24, 2024

Allegation investigated: Licensee became power of attorney of a resident

Licensing Program Analysts (LPAs) Rosaura Valenzuela, Leizl De La Cera, Milena Khurshudyan and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced subsequent visit to deliver the findings for the above noted allegation. LPAs and LPM met with Licensee Emma Topadzuikyan and explained the reason for the visit. It was reported that Licensee became power of attorney of a resident #1 (R1). To investigate this allegation on 3/06/2024, LPAs Valenzuela and De La Cera made an unannounced initial visit. Between 11:00am and 11:30am, a physical tour was conducted. LPAs observed five residents in care. Between 11:30am and 1:15pm, facility records were reviewed. LPAs noted that facility files were incomplete. As per LPAs request, on 3/08/2024, Licensee emailed facility records for Resident #1 (R1) to LPA Valenzuela. Records requested included, but not limited to R1's physician's report, need and service plan, emergency contact information, a copy of R1's Durable Power of Attorney (POA) and etc. On 3/06/2024, between 1:15pm and 1:30pm , resident interviews were initiated. Interviews did not reveal anything since R1 was not able to respond to the Continue on 9099-C Substantiated questions. From 1:30pm to 2:30pm, LPAs initiated staff interviews. At the time of the interview the Administrator, Staff #1 (S1) admitted that after R1 moved to the facility, they became R1's medical and financial durable power of attorney. Prior to this visit, on 3/11/2024, between 1:00pm and 3:00pm, LPA reviewed the facility records. Records revealed that S1-Licensee/Administrator is R1's medical and financial POA. Furthermore, records also revealed that an unknown individual, who has no connection to R1 is also listed as on of the Power of Attorneys for R1. Based on interviews and records review there is sufficient information to verify this allegation. Therefore, this allegation is SUBSTANTIATED at this time. Pursuant to the California Code of Regulations, Title 22, the following deficiencies were observed and cited during this visit. No other health and safety hazards are noted during this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 31-AS-20240301091558

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58(a)(5) · Plan of correction due date: Mar 13, 2024

1569.58 Persons prohibited from being a licensee, owning beneficial interest in licensed facility-(a) The Department may prohibit any person from being a licensee...or being an administrator, member, or manager of a licensee...and my further prohibit any licensee from employing, or continuing the employment of...or allowing contact with clients of a licensed facility...who has done any of the following: (5) Engaged in acts of financial malfeasance concerning the operaton of a facility, including but not limited to, improper use or embezzlement of client moneys and property or fraudulent appropiattion for personal gain of facility moneys and property. This requirement was not met as evidenced by: Based on interviews and records review, the Licensee became R1's health care and financial power of attorney. This posses an immidiate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The Licensee will submit written sttement explaining the steps she will take to remedy the cituation. The document must be submitted to the Licensing Department within 24 hours,

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(d)(2)(f) · Plan of correction due date: Mar 13, 2024

87217(d)(2)(f) Safeguards for Resident Cash, Personal Property, and Valuables (d)(2)...no licensee or employee of a facility shall; accept any general or special power of attorney for any resident. This requirement was not met as evidenced by: Based on interviews and records review the Licensee became R1's POA. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The Licensee will submit written sttement explaining the steps she will take to remedy the cituation. The document must be submitted to the Licensing Department within 24 hours,

Type of visit: Case Management - Deficiencies

This Case Management is conducted in conjunction with complaint control number 31-AS-20240301091588 to address the issues unrelated to the complaint. During the complaint investigation visits conducted on 3/06/24 and today 3/12/24 LPAs were informed that facility retains Resident #2 (R2) who developed Stage 4 Pressure injury while in care of the facility. On 3/06/24, the Licensee/Administrator was interviewed and she verified that R2 was a long-term resident and had a history of developing pressure injuries. Prior to this visit, LPA Valenzuela and LPM Margaryan contacted hospice agency to request Hospice records for R2. The records were e-mailed to the LPM Margaryan on 3/12/24 at the time of Licensing visit. A review of hospice records revealed that on or before 2/26/24, R2 developed pressure injuries. Stage 4 pressure injury on Right Buttock and sacrum. According to wound care records, between 2/28/24 and 3/11/24 R2's pressure injuries were not healing. The records also indicate that due to condition of the wounds' infection is suspected. Overall investigation regarding R2's pressure injuries revealed that although R2 is receiving hospice services and wound care is provided, R2's pressure injuries were not healing and may result in an infection. Based on observation, interviews and record review, it was concluded that the facility retains the resident that developed prohibited health condition and require a higher level of care. R2's health condition and other noted issues were discussed with the Licensee/Administrator and she was informed that at this time the facility is not in compliance with Title 22 Regulations. The Licensee/Administrator also was informed that an immediate Civil Penalty of $500.00 will be issued for retaining a resident who developed a prohibited health condition. Under Title 22 Division 6, Chapter 8, following deficiency was cited and recorded on LIC809D. No other health and safety hazard is noted during this visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a) · Plan of correction due date: Mar 26, 2024

87615 Prohibited Health Conditions-(a) Persons who require health services for or have a health condition including but not limited to, those specified below shall not be admitted or retained at a residential care for the elderly. (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on interviews and records review, the administrator retained a resident with stage 3 and 4 pressure injuries in the facility. This posses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The administrator will submit in writing to CCL by 3/13/24, how they will correct the cituation and to ensure that moving forward residents with stage 3 or 4 pressure injuries are not accepted or retained in the facility.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Rosaura Valenzuela, Leizl De La Cera, Milena Khurshudyan and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced subsequent Case Management visit in conjunction with complaint control number 31-AS-202403109588. The purpose of this Case Management visit is to issue citations for the deficiencies that were observed during the course of the complaint investigation that is not directly related to the complaint. LPAs and LPM met with the Licensee Emma Topadzuikyan and explained the reason for the visit. During the investigation, LPAs observed the following: 1) R1 has dementia and the last time that they were medically assessed was in 2019. 2) Hospice records are incomplete for R1 and for Resident #2 (R2) 3) R2's facility file is incomplete 4) Incident reports for both R1 and R2 were not submitted to the Licensing Department 5) Hospice information was incomplete for both R1 and R2 6) Lack of Administrator qualifications Pursuant to the California Code of Regulations, Title 22, the following deficiencies were observed and and cited during this visit. Exit interview conducted and a copy of the report and citations were issued.the state’s words, verbatim · CDSS document, Mar 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Mar 26, 2024

87705(c)(5) Care of Persons with Dementia-Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually both of which shall include a reassessment of the resident's dementia care needs. This requirement was not met as evidenced by: Based on records review, the Licensee did not have a resident with dementia annually medically assessed. R1's last medical assessment was conducted in 2019. This posses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The Licensee shall submit in writing to the Department by 3/26/2024 how they will ensure that all residents with dementia are medically assessed annually and reappraised annually or when a change in condition has been observed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(h)(3) · Plan of correction due date: Mar 26, 2024

87633(h)(3) Hospice Care of Terminally Ill Residents (h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record (3) A copy of the written certification statement of the resident's terminal illness from the medical director of hospice... This requirement was not met as evidenced by: The licensee did not provide the Department representative with this documentation. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The licensee shall submit in writing by 3/26/24 to Licensing Office, how they will ensure that residents in hospice have complete hospice records.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 26, 2024

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to the licensing agency staff. This requirement was not met as evidenced by: The Licensee did not present to Licensing agent complete resident records for R2. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The Licensee shall submit in writing by 3/26/24 to the Department how they will ensure that all resident files are complete.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(B) · Plan of correction due date: Mar 26, 2024

87211(a)(B) Reporting Requirements-(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency for (B) any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by: The Licensee did not notify the Department that residents had entered hospice care and did not submit incident reports for residents. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The Licensee shall submit in writing by 3/26/24, how they ensure that any serious incident reports and hospice notifications are submitted to licensing in a timely manner.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1)(2) · Plan of correction due date: Mar 26, 2024

87405(d)(1)(2) Administrator Qualifications and Duties-The Administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). (2) Knowledge of the ability to conform to the applicable laws, rules, and regulations... This requirement was not met as evidenced by: Licensee did not ensure that the Administrator has enough knowledge to comply with Title 22 Regulations. Based on interviews and record review, the facility is not in compliance with Title 22 Regulations. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: The administrator will enroll and take more administrator courses and provide proof of enrollment to CCLD by 3/26/24.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Rosaura Valenzuela and Leizl De La Cera conducted an unannounced Case Management visit in conjunction with complaint control number 31-AS-20240301091558. The purpose of this Case Management visit is for deficiencies observed during the course of the complaint investigation that is not directly related to the complaint. LPA met with Emma Topadzuikyan,,Administrator. During the investigation, LPA Valenzuela and LPA De La Cera observed the following: 1) Resident #1(R1) has a stage 4 pressure injury. 2) R1 has dementia and the last time she was reappraised was in June of 2019. 3) Hospice records incomplete for R1 and R2. 4) Resident #1 and #2 (R2)'s facility files are incomplete 5) Incident reports for both R1 and R2 not submitted to licensing. 6) Hospice notification for both R1 and R2 not submitted to licensing. 7) Lack of Administrator qualifications Due to time constraints, citations will be issued on a following visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 6, 2024