Oakdale Gardens Assisted Living

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Evelin Rios conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20260812125848. LPA met with Staff #1 (S1), who granted access to facility. LPA's review of Guardian indicated, S1 is not Background finger printed cleared, immediate civil penalty will be issued in LIC 421BG. According to the administrator S1 started working yesterday. During record review, LPA observed that R1 has their P&I money in their file locked in a closet inaccessible to R1 with out assistance from administrator designee who has the key. According to the administrator designee R1 requested their money is held for safe keeping. Administrator designee also stated that they have only held R1's money for July and August. LPA requested a copy of the facility's Surety Bond and administrator designee stated they did not have one. Citations issued in 809D. Exit interview conducted. Appeal rights given and a copy of this report provided to the administrator designee.the state’s words, verbatim · CDSS document, Aug 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 19, 2026

(e)All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidence by: Based on interview and review of Guardian Background System Check, Facility Staff criminal background is not cleared and not associated to the facility. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Administrator has agreed to complete and background clearance and Guardian Association to facility and submit proof to the department by POC due date. S1 is not to return to the facility until they are associated to the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87216(a) · Plan of correction due date: Aug 21, 2026

(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement is not met as evidence by: Based on interviews and record review the facility does not have a Surety Bond but is safeguarding R1's cash which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Administrator designee has agreed to return R1's cash and provide a safe place for R1 to maintain their cash in their bedroom. A statement of understanding regarding the regulation cited will be sent to the Department by POC due date.

Allegation investigated: Facility is operating over capacity. Staff are not ensuring residents are provided with a proper place to sleep. Staff are not providing adequate food service to residents in care.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Elen Gabrielian and explained the reason for the visit. LPA spoke with the administrator, Marine Zhigoyan, who designated Gabrielian to sign and accept the report. --- Facility is operating over capacity. It was alleged that Resident #1 (R1) and their roommate, Resident #2 (R2), are sleeping in a car for part of the night and that facility staff bring them back inside during the early morning hours. To investigate the allegation, LPA conducted a physical plant tour and requested documents at around 10:00a.m., interviewed two (2) staff from 10:30a.m. – 11:30a.m., and interviewed four (4) out of six (6) residents from 11:30a.m. -12:30p.m. (CONT. LIC9099-C) Unsubstantiated During the physical plant tour, LPA observed five residents in the facility and seven beds. A review of the Department’s incident reports did not reveal any issues regarding capacity during the time in question. A review of R1’s Physician’s Report states hearing loss, vision loss (glasses – assistive device) and not able to leave the facility unassisted. During interviews, all staff stated they have never asked or forced anyone to sleep outside. Staff added R2 has a single occupancy room, R1 shares a room with Resident #3 (R3) and the seventh bed near the kitchen is for staff resting area only. During interviews with residents, R1 stated they and their roommate, R3, slept in a car for part of the night and that facility staff brought them back inside during the early morning hours but that ended about two (2) days ago. One (1) out of six (6) residents stated they are unaware of how many residents live here. Two (2) out of six (6) stated there are six residents living here in total. LPA was unable to interview the remaining two (2) residents. Based on interviews, record review and observations, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff are not ensuring residents are provided with a proper place to sleep. It was alleged that facility has eight (8) beds and fifteen (15) residents in the home. To investigate the allegation LPA conducted a physical plant tour and requested documents at around 10:00a.m., interviewed two (02) staff from 10:30a.m. – 11:30a.m., and interviewed four (4) out of six (6) residents from 11:30a.m. -12:30p.m. During the physical plant tour, LPA observed five residents in the facility and seven beds. A review of the Department’s incident reports did not reveal any issues regarding bed security during the time in question. During interviews, all staff stated there are six (6) residents in the facility, and all have a bed. Staff added no resident has ever gone without a bed in the facility. During interviews with residents, R1 stated there are fifteen (15) residents in the facility and only eight beds. All other residents stated they have never been without a bed. Based on interviews, record review and observations, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT on LIC9099-C) --- Staff are not providing adequate food service to residents in care. It was alleged that R1 is receiving only two meals per day, and sometimes fewer. To investigate the allegation LPA conducted a physical plant tour at around 10:00a.m., interviewed two (02) staff from 10:30a.m. – 11:30a.m., and interviewed four (04) out of six (06) residents from 11:30a.m. -12:30p.m. During the physical plant tour, LPA observed snacks being offered and served and well-balance meals being prepared and served. During interviews, all staff stated they serve residents breakfast, lunch and dinner and offer snacks. During interviews with residents, R1 stated facility serves breakfast, lunch and dinner. R1 added that if they get hungry again they are offered snacks such as peanut butter sandwiches. All other residents stated they are served breakfast, lunch and dinner with snacks if they request. Based on interviews and observations, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 31-AS-20260421153725

Type of visit: POC

On 7.8.2026 at 12:30 PM, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda, arrived at the facility to conduct an unannounced, Plan Of Correction (POC) and was greeted by staff. The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 4.29.2026. At 11:45 AM LPA toured the facility and requested the following: - LPA cleared the POC that required LIC 9020. - Administrator remove S2 from the facility. - R6 files were completed. During LPA visit, it was observe that the bed was remove for staff in the kitchen, but was replace with a sofa bed. S2 was remove, but replace with another staff that is not background clear. Two (2) citations will be issued on 809-D. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 cited and noted on LIC 809-D. An exit interview was conducted, citation(s) were issued, appeals rights and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jul 9, 2026

The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records ... employment, residence, or initial presence in the facility. This requirement is not met as evidence by: Based on interview and review of Guardian Background System Check, Facility Staff criminal background is not cleared and not associated to the facility. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Administrator has agreed to complete Guardian Association and background clearance to facility and submit proof to the department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(2)(b) · Plan of correction due date: Jul 22, 2026

a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply: (2) …: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. Based on observations a bed was observed in the kitchen in which staff stated to sleep, licensee did not ensure to provide an adequate space for staff which poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Administrator will provide proper area for staff and will submit pictures to the department by POC due date.

Allegation investigated: Staff do not ensure residents sleeping accommodations are being met. Staff do not ensure medications are dispensed as prescribed to resident. Staff did not provide adequate meals.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the staff designee (S1), Ani Ghazaryan, and explained the reason for the visit. To investigate the allegation on 04.29.2026, LPA took a tour of the physical plant at 8:35 AM. LPA requested copies of resident #1 (R1) physician report, admission agreement, appraisal needs and service plan, and other documents pertaining to the investigation. LPA reviewed documents at 11:00 AM, interviewed two (2) staff and five (5) residents who are at the facility from 8:47 AM to 10:59 AM. Allegation: Staff do not ensure residents sleeping accommodations are being met. It was alleged that staff told resident #1 (R1) and resident #5 (R5) to sleep in the car part of the night. During physical plant tour at 8:35 AM, LPA observed that R1 and R5 are residing comfortably in a shared bedroom. Continue to LIC 9099-C Unsubstantiated Interview with residents stated that allegation is false and they are comfortable and happy residing at the facility in their assigned bedroom. Interview with staff revealed that R1 and R2 reside in a shared bedroom and stated that allegation is false. LPA called and spoke to witness #1 (W1) at 10:13 AM, revealed that they are happy with the care and supervision of the facility and allegation is false. Based on observation and interviews, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff do not ensure medications are dispensed as prescribed to resident. It was alleged that staff did not ensure R1 medications are dispensed as prescribed. LPA interview with residents present at the facility stated that they have no issues with medication. Interviews with staff revealed that they follow the prescription and dispense medication as indicated by the prescribing physician. LPA reviewed five (5) residents Centrally Stored Medication and Destruction Records (CSMDR) and medications. Based on LPA observation, medication was accounted for all the residents on CSMDR and medication in the facility. Based on observation and interviews, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff did not provide adequate meals. It was alleged that staff failed to provide R1 with adequate and appropriate meals. Interview with residents revealed that they have no complaints or concerns regarding the meals and believed the food provided was nutritious to their dietary needs. At 9:30 AM LPA observed a healthy and nutritious breakfast being served to the residents. LPA conducted a tour of the kitchen and food storage areas. LPA observed that the facility had a fully stocked supply of food, including sufficient quantity of perishable and non-perishable items. LPA also observed the breakfast served during the visit was observed to have an adequate portion size and appeared nutritious (fruits, oatmeal and toast). Interview with staff indicated that the facility consistently maintains sufficient food supplies and that meals are prepared daily. Interview with residents revealed that facility staff caters to their special diet and meals are served appropriately. Based on observation and interviews, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 31-AS-20260421114247

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted unannounced initial visit to this facility in conjunction with a complaint control #31-AS-20260421114247. LPA met with Staff #2 (S2) Mina Mavromati, who granted access to facility. S2 is not associated with facility, immediate civil penalty will be issued in LIC 421BG. During physical plant tour it was observed that S2 has a bed in the kitchen and S2 stated at 8:32AM that it’s their bed. During record review, the following were observed: · R6 not having a file at the facility, they have been residing at the facility for more than a week. · S1 failed to provide LIC 500 and LIC 9020. Citations issued in 809D. Exit interview conducted, Appeal rights given and a copy of this report delivered.the state’s words, verbatim · CDSS document, Apr 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Apr 30, 2026

The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records ... employment, residence, or initial presence in the facility. This requirement is not met as evidence by: Based on interview and review of Guardian Background System Check, Facility Staff (S2)’s criminal background is not cleared and not associated to the facility. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Administrator has agreed to complete Guardian Association of S2 and background clearance to facility and submit proof to the department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(A) · Plan of correction due date: May 13, 2026

Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident,... of the resident’s home health agency, if any, and any other. appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement is not met as evidenced by: Based on document review R6 does not have a file at the facility, which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Administrator will create a file for R6 and submit copies to the department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87508(c) · Plan of correction due date: May 13, 2026

The register of current residents shall be kept in a central location at the facility. Based on document review a register of current residents was not available, which poses a potential risk to the persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Facility administrator will provide LPA an updated LIC 9020 by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(2)(b) · Plan of correction due date: Apr 29, 2026

a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply: (2) …: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. Based on observations a bed was observed in the kitchen in which staff stated to sleep, licensee did not ensure to provide an adequate space for staff which poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Administrator will provide proper area for staff and will submit pictures to the department by POC due date.

Type of visit: Prelicensing

On 9/12/2025 at 1:30PM Licensing Program Analyst (LPA), Perchui Milena Khurshudyan conducted an announced Pre-Licensing visit to the above facility and met with facility Licensee/Administrator Zhigoyan Marina. LPA introduced herself by showing the department badge. Fire Clearance was approved on 6/10/2025 for a maximum capacity of six (6) Non-ambulatory residents, of which one (1) Bedridden resident for bedroom #3. Facility has a Dementia Care Program. The facility also has Hospice waiver for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: KITCHEN: The facility has an open floor kitchen area that is equipped with a new refrigerator, microwave oven and sink. At 2:00pm, LPA observed adequate supplies of nonperishable food properly stored in the cabinets and inside the supply room. Perishable food items are not required at this time as there are no residents in the facility. LPA observed dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked inside a kitchen cabinet and inaccessible to residents in care. The facility has one (1) new fire extinguisher, appeared to be full and serviced and were last purchased on 6/13/2025. BEDROOMS: There are four (4) bedrooms in the facility and all bedrooms are designated for residents’ use. All bedrooms observed to be furnished with beds, dressers, chairs, night stands and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational at 2:15pm. Facility will have awake staff at night. Emergency call buttons will be provided to residents. Continue on LIC809C LAUNDRY ROOM: The laundry room is located in a separate area /closet next to the dining area. The washer/dryer appears to be new and in good condition. Laundry supplies along with other chemical items will be kept locked inside the cabinets and under supervision when not in use. BATHROOMS: The facility has four (4) bathrooms. At 1:45PM LPA observed all bathrooms are clean, in good repair and properly supplied with toilet paper, soap and paper towels. LPA observed appropriate grab bars and non-skid mats in all bathrooms. Trash cans had closed tight fitting lids throughout the facility. Water temperature was within regulation, and it was measured by an LPA at 10:55AM to be at 116°F degrees. All bathrooms are designated for Staff and residents’ use. COMMON AREAS: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. The facility has activity puzzles, coloring books, crayons, board games and other activity supplies available for residents. No obstructions or tripping hazards throughout the facility. An emergency exit plan/sketch is posted along the hallway with other posting requirements. No fire-arms observed or will be maintained on the premises. MEDICATION ROOM: The medication will be centrally stored inside the locket cabinet located in the common area next to the kitchen. Facility staff/resident files will be kept centrally stored and locked inside the commercial cabinet located in the office room. First-aid kit was checked to be complete and has the new manual available. The facility will have two (2) staff members for each shift (AM and PM). SMOKE DETECTORS/CARBON MONOXIDE. Dual smoke detectors and carbon monoxide throughout the facility. At 2:30 PM they were tested and observed to be operational. SURROUNDING GROUNDS: The facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The backyard is fenced. There is no garage on the property. LPA observed the resin storage shed placed in the backyard. LPA discussed the importance of maintaining care and supervision to meet the needs of the residents. The facility has land line, checked by an LPA to be operational. Component III was conducted with the Administrator.Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will be notified by the CAB Analyst when the license has been approved. Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.the state’s words, verbatim · CDSS document, Sep 12, 2025