Our Sweet Home Inc. #2

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced continuation of the annual inspection. LPA met with staff and disclosed the reason for the visit. LPA conducted a file review of resident records to ensure compliance of licensing forms. LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Medication and Medication Records were review for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff, Herman Ledesma, and explained the reason for the visit. Administrator Tina Arutyunyan was not able to join today's visit. At approximately 02:15 pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food sealed and properly stored. Knives were stored in a locked drawer. LPA observed medications are centrally stored and locked in a kitchen cabinet and inaccessible to residents in care. LPA observed the fire extinguisher is located in the kitchen. The purchase date is 09/24/25. Bedrooms: There are five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Currently, Bedroom#3 and #4 are vacant. Auditory alarms were tested and observed to be operational. Staff bedroom is located by the living room. Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 108.6 F. No cleaning supplies were observed in either bathrooms during the day of the inspection. Common Areas: These included the living room, family room and dining area. The common areas were properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. Staff Workstation/Office: There is a staff workstation located at the corner of the living room. Laundry area: The laundry area is located adjacent to the garage. No cleaning supplies or detergents present during inspection. Cleaning supplies and detergents are kept in the garage, that has a locked entry. Garage: The garage is attached to the building. It is used for storage space to keep cleaning supplies and detergents. Entry to garage is kept locked at all times. Due to time constraints, LPA was unable to complete the annual inspection during today's visit. The Administrator was informed that a follow-up visit will be conducted. Today's the facility complies with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 29, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff, Herman Ledesma, and explained the reason for the visit. Administrator Tina Arutyunyan had arrived later to the facility. At approximately 10:00 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. LPA observed dual smoke and carbon monoxide detectors were located throughout the facility, and they were tested and observed to be operational. The fire extinguisher is located in the kitchen. The purchase date is September 24,2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food sealed and properly stored. Knives were stored in a locked drawer. LPA observed medications are centrally stored and locked in a kitchen cabinet and inaccessible to residents in care. Bedrooms: There are five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Staff bedroom is located by the living room. Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 106.7 F. No cleaning supplies were observed in either bathrooms during the day of the inspection. Common Areas: These included the living room, family room and dining area. The common areas were properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. (Continue on 809C) Surrounding Grounds: The backyard was large enough to hold outdoor activities. LPA checked the side gate to insure no locks installed, and that it is clear to exit/evacuate in case of an emergency. The outdoor area was free of hazards. Staff Workstation/Office: There is a staff workstation located at the corner of the living room. Laundry area: The laundry area is located adjacent to the garage. No cleaning supplies or detergents present during inspection. Cleaning supplies and detergents are kept in the garage, that has a locked entry. Garage: The garage is attached to the building. It is used for storage space to keep cleaning supplies and detergents. Entry to garage is kept locked at all times. Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. LPA observed that R2 has half rail without a written order from a physician indicating the need for the postural support. LPA also observed that R4 and R5 have no updated physician report (LIC 602). Administrator was advised to provide the requested documents promptly. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Medications: Medications are stored in a locked cabinet in the kitchen. Medication and Medication Records were reviewed for proper storage and documentation. Exit interview conducted, citations issued, appeal rights given and copy of the report delivered.the state’s words, verbatim · CDSS document, May 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Herman Ledesma, and explained the reason for the visit. Currently the administrator is out, but Hermon is designee to sign off on the licensing report. At approximately 12:15pm, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building, licensed to serve residents age 60 and above. Required postings were observed in the entry area. The smoke alarms are hardwired. The carbon monoxide detector is located by staff workstation. There is one fire extinguishers, located in the kitchen. It was purchased on September 12, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food sealed and properly stored. Knives were stored in a locked drawer. No cleaning supplies were observed. Bedrooms: There are six (6) bedrooms. Five (5) are designated for residents' use. One bedroom (#6) is reserved for staff. Bedroom #2 is shared. Bedrooms #1 and numbers 3 to 5 are private. Bedrooms, in use by the residents were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 114 and 118 degrees Fahrenheit. No cleaning supplies were observed in either bathrooms during the day of the inspection. Common Areas: These included the living room, family room and dining area. The living room was furnished with three couches and a table. The family room is furnished with four (4) recliners, one (1) chair, a table and television. The dining room table is large enough to seat up to six (6) individuals. Furniture were observed to be in good repair. Floors were mopped and clean. Exits and Passageways were clear. Surrounding Grounds: The backyard was large enough to hold outdoor activities when the weather permits. LPA checked the side gate to insure no locks installed, and that it is clear to exit/evacuate in case of an emergency. The outdoor area was free of hazards. Laundry area: The laundry area is located adjacent to the garage. No cleaning supplies or detergents present during inspection. Cleaning supplies and detergents are kept in the garage, that has a locked entry. Staff Workstation/Office: There is a staff workstation located at the corner of the living room. Resident Files: Resident files are kept in cabinet in the living room. LPA reviewed files to insure compliance. Staff Files: Staff files are also kept in the same cabinet where resident files are maintained. LPA conducted a file review of staff records to insure forms and training are up to date. Medications: Medications are stored in a locked cabinet in the kitchen. Medication and Medication Records were reviewed for proper storage and documentation. Garage: The garage is attached to the building. It is used for storage space to keep cleaning supplies and detergents. Entry to garage is kept locked at all times. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed, but one advisory for a technical violation was issued today. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, May 31, 2024

Allegation investigated: Staff did not administer medication to resident while in care.

This is report is to amend the LIC9099 report issued 03/18/2024. Additional information was added to clarify the investigation pertaining to allegation mentioned above and based on new information obtained the determination for the above allegation is changed from Unsubstantiated to Substantiated. On 04/09/2024 Licensing Program Analysts (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit to obtain additional information. Upon arrival LPA met with staff, Hermon Ledesma. Hermon contacted the Administrator, Tina Arutyunyan by telephone and LPA explained the purpose of the visit. Tina met LPA shortly after. An entrance interview was conducted. Tina provided medication administration record (MAR) for resident #2 (R2) for December 2021. Tina was unable to provide documentation showing medication for December 2021 was filled by a pharmacy or documentation resident #1 (R1) was seen by a doctor to prescribe medication after Hospice discharge date 10/14/2021. LPA interviewed Hermon Ledesma at approximately 11:30 a.m. and conducted review of current medications and medication records at approximately 2:45 p.m. (Continued on LIC9099-C) Substantiated (Continued from LIC9099) Administrator could not stay to sign todays report and designated Hermon Ledesma, staff to sign. Allegation: Staff did not administer medication to resident while in care. It is alleged facility failed to provide medication during the time R1 was discharged from Hospice. To investigate this allegation on 05/17/2022 LPAs Joscelyn Martinez and Tuesday Cabiness conduct an the initial complaint visit. Review of Medication Administration Records (MAR) on 05/17/2022 for the time period in question revealed medication listed on MAR was checked off as being provided after Hospice discharge date of 10/14/2021 to 12/16/2021 but not checked off as being provided from 12/17/2021 to 12/31/2021. Facility is not able to provide MAR or Centrally Stored Medication or Destruction Records for the first week of January 2022 before R1 was sent to the hospital. LPA Martinez notes Medication documentation picks up again on February 2022. On 05/17/2022 LPAs Martinez and Cabiness conducted interviews with four (4) out of four (4) residents and on 03/18/2024, LPA Rios conducted interviews with 4 out 4 residents. Resident interviews revealed they cannot recall experiencing missed medication, or medication errors. According to interview on 03/18/2024 with staff responsible for assisting residents with medication they deny the allegation and they state they have always provided medication as directed. Interview with staff on 04/09/2024 revealed they cannot recall why MAR was not filled in for 12/17/2021 to 12/31/2021, but they are certain medication was provided. Interview on 05/17/2022 with staff revealed that during that time they forgot to fill MARs for the month of January 2022. On 04/03/2024 LPA Rios conducted an interview with a representative from R1's former hospice agency that revealed, Hospice handled prescribing and making sure medications were filled by Hospice pharmacy for R1. Furthermore, Hospice agency representative revealed they would have provided at most a 2 to 4 weeks supply of medication after discharge date of 10/14/2021, while R1 made an appointment with primary doctor. Interview with administrator on 03/18/2024 and again on 04/09/2024 still denies the allegation and they state medication has always been provided. Review of records on 04/09/2024 revealed, facility kept medication administration records (MAR) for December 2021 to document medication assistance. MAR for residents during the month of December 2021, revealed resident #2 (R2) unlike resident #1 (R1) was not missing recorded days of medication for 12/17/2021 to 12/17/2021. Indicating facility failed to properly record medication administration for R1. Based on facilities own MAR documentation showing the discrepancy between R1 and R2 and the facility unable to provided documentation for R1 showing medication was filled by a pharmacy or a medication list provided by a doctor for time period 12/17/2021 to 01/06/2021 the determination for allegation; staff did not administer medication to resident while in care is Substantiated. Deficiency cited (refer to LIC9099D). Appeals discussed and provided. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 31-AS-20220509135641

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 10, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA's observation and record review, the facility failed to provide records, showing medications were provided to R1 from 12/17/2021 to 01/06/2022 which poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2024

Plan of correction: Review of residents medication records for the month of May 2022 were noted as in compliance by LPA Martinez. Review of medication and medication records for April 2024 reviewed by LPA Rios are in compliance. Based on current medication compliance administrator will provide to LPA a statement of understanding for the cited regulation by POC due date.

Allegation investigated: Staff did not provide medical assistance to resident while in care. Staff did not administer medication to resident while in care.

On 03/18/2024 Licensing Program Analysts (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival LPA met with staff Hermon Ledesma. Hermon contacted the Administrator, Tina Arutyunyan by telephone and LPA explained the purpose of the visit. Tina could not meet LPA on todays visit and designated Hermon to sign todays report. LPA informed Tina to be available by telephone if LPA called requesting more information. At approximately 10:25 a.m. LPA conducted a physical plant tour of the facility and interviewed Hermon. At approximately 11:17 a.m. LPA conducted interviews with four (4) out of four (4) residents in the home. At approximately 11:43 a.m. LPA reviewed and obtained resident's #1 (R1's) admission agreement, physician's reports, appraisal needs and services plan, identification and emergency information, and Hopsice records on file. LPA also reviewed facility program in reference to medication procedure and medication documentation. At approxemetly 1:15 p.m. LPA interviewed Tina by telephone. (Continued on LIC9099-C) Unsubstantiated Allegation #1: Staff did not provide medical assistance to resident while in care. It is alleged resident #1 (R1) had a medical emergency at the facility, and staff did not seek medical attention. To investigate this allegation LPAs Joscelyn Martinez and Tuesday Cabiness conducted an initial complaint investigation on 05/17/2022. They interviewed four (4) residents including R1, interviewed staff present and reviewed and obtained resident records. Interview with residents on 05/17/2022 and 03/18/2024 revealed they are satisfied with the assistance being provided and are confidant staff can determine if they are having a medical emergency and will call 911 if needed. Interview with staff on 03/18/2024, staff denied the allegation and revealed R1 may seek attention sometimes and or omit information from staff later revealing they may have been experiencing symptoms from medication. Interview with staff on 05/17/2022 revealed on day in question staff was present and according to them R1 had reported shortness of breath but then stated they were ok. According to staff they contacted R1's relative and they insisted R1 be taken to the hospital. Discharge paper work obtained by LPA Martinez revealed R1 was recommended a medical procedure. Interview with R1 on 05/17/2022 revealed on the day in question they had complained about shortness of breath but that it was not true. When LPAs asked why R1 stated so, R1 stated they wanted to get out of the facility because they felt stuck there. R1 went on to state they did not feel ill and were not experiencing any symptoms. Based on information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. Allegation #2: Staff did not administer medication to resident while in care. It is alleged facility failed to provide medication during the time R1 was discharged from Hospice. To investigate this allegation on 05/17/2022 LPAs review of Medication Administration Records (MAR) for the time period in question revealed medication listed on MAR was provided. Interviews with four (4) residents on 05/17/2022 and four (4) out of four (4) residents on 03/18/2024 revealed they cannot recall ever experiencing missed medication, or medication errors. According to interview on 03/18/2024 with staff responsible for assisting residents with medication they deny the allegation and they state they have always provided medication as directed. On 03/18/2024 LPA's review of R1's physician's report for examination done on 06/24/2022, revealed R1 was not receiving Hospice care and a terminal illness was not specified. According to a telephone interview with Administrator on 03/18/2024, R1 was discharged from Hospice and not receiving Hospice care for about two years. Administrator states R1 is now receiving Hospice care. LPA's review of R1's Hospice records revealed last entry was made on 05/20/2021 for a medication that LPA reviewed on MAR was documented as being provided during period in question. Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report signed and delivered.the state’s words, verbatim · CDSS document, Mar 18, 2024 · control 31-AS-20220509135641

Allegation investigated: Staff did not assist resident in a timely manner Staff threatened resident in care

This is an amended report of the prior investigation report delivered on 02/02/24. Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced visit to this facility. LPA met with Administrator Designee Hermon Ledesma and explained the reason for the visit. Based on the information LPA gathered LPA determined that the allegations are unfounded. R1 doesn’t live at the address stated on the complaint report. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. This agency has investigated the complaint alleging (Staff did not assist resident in a timely manner and Staff threatened resident in care). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and copy of this report issued Unfoundedthe state’s words, verbatim · CDSS document, Feb 2, 2024 · control 31-AS-20240126125534