Queen Comfort Care Center

Allegation investigated: Facility staff did not seek timely medical attention for resident resulting in hospitalization. Facility staff were unable to answer communications from resident's representatives.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Urena met with the Administrator Nino Gelashvili and explained the reason for the visit. On 06/10/2025, the Woodland Hills North (WHN) Regional Office (RO) received the complaint C#29-AS-20250610125339 which was investigated by the Department. On 06/12/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 24-hour visit to investigate the allegations listed above and met with the licensee. On this date the LPA collected documents pertinent to the investigation. Continues on LIC 9099C... Unsubstantiated During the course of the investigation, on 08/25/2025, and 10/23/2025, interviews were conducted with Licensee Representative Nino Gelashvili. On 09/17/2025, interviews were conducted with R1’s responsible party. Facility records, along with hospital and hospice care records were also reviewed. On the allegation ‘Facility staff did not seek timely medical attention for resident resulting in hospitalization’, it was alleged that the licensee did not call 911 following an incident that occurred approximately two weeks after R1 arrived when R1 needed to be transported to the hospital. During the interview with the licensee, they acknowledged that on 10/10/2024, they observed R1 appearing weak due to barely eating. The licensee stated it was R1’s responsible party who did not want to call 911 at the time. Although, she called 911 and had R1 transported to the hospital after consulting the hospice care nurse. The licensee stated prior to this transfer, R1 was eating regularly and communicating with staff verbally. The licensee provided a copy of a text message thread that stated, “Please call. The whole family is saying to call 911. I don’t want to stay on my decision of not calling 911.” Although there is no indication of the date when this text message was sent nor any phone numbers verifying where the text message came from. During the interview with R1’s responsible party, they denied not wanting to call 911. Record review reflects, R1 received a Comprehensive Nursing Assessment by hospice on 10/08/24. The resident was observed to be non-responsive, non-verbal, disorientated, and confused. It is noted that at the end of the visit, the patient was comfortable and safe. Hospital records reflect on 10/10/2024, the resident was hospitalized due to weakness and being non-verbal. The Unusual Incident Report (LIC 624) submitted to the Department by the licensee indicates on 10/10/24, R1 was a “little weak” and ate “very little” of their breakfast. It was noted their vitals were okay, but hospice was still notified. When the hospice nurse arrived, they advised vitals were okay. It was noted that R1’s responsible party did not want R1 transported because they were “very angry” with the previous hospital. However, since the responsible party did not have Power of Attorney, 911 was called by the licensee. Therefore, based on the information obtained during the course of the investigation, the allegation of ‘Facility staff did not seek timely medical attention for resident resulting in hospitalization’ is deemed Unsubstantiated at this time. Continues on LIC 9099C... Facility staff were unable to answer communications from resident's representatives. On the allegation that staff could not communicate with R1’s responsible representatives (RP), it is alleged that R1’s RP were not able to communicate with any of the care staff because none of them spoke English. To investigate the allegation LPA Urena interviewed staff and the Administrator. The staff's interview revealed that the staff have limited communication skills in English, however, the staff was able to answer the LPA's basic questions and was quick to call the Administrator to answer any additional questions. The Administrator reported that although the staff’s communication ability is limited, they understand English. Furthermore, the Administrator stated that they and the Licensee could have answered questions if needed. The RP reported speaking with the Administrator and expressing their concerns about R1’s condition. Furthermore, the R1’s representative communicated with the Administrator and discussed R1’s needs and need for treatment, as the concern of the RP was about R1’s declining health and change in condition. Although the allegation may have happened or is valid, based on the interviews, the RP did have an option of communicating with the Administrator or Licensee to communicate their concerns on the change of condition of R1, consequently there is not sufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided. On the allegation that the facility staff did not properly assess resident prior to admission, it is the concern of the reporting party (RP) that when R1 initially arrived at the facility via ambulance to be admitted at the facility, R1 appeared very ill, almost “on the verge of death, and the RP felt that the staff should never have allowed R1 to remain at the facility and should have had R1 transported to a hospital. During interviews, Nino Gelashvili, the licensee acknowledged that when R1 arrived at the facility R1 indeed appeared very “weak,” and was also nonresponsive (not verbally communicating). Licensee also acknowledged she had not seen R1 prior to their arrival and admission at the facility; however, licensee had been in communication with R1’s social worker at the hospital in Stockton prior to R1’s arrival. Licensee stated that prior to R1’s arrival, the social worker sent to the licensee R1’s “Physician Report” signed by a doctor on 09/23/2024. Licensee stated that the Physician’s Report indicated that R1 was “independent,” which the licensee observed was not the case when R1 arrived. Furthermore, based on the record review of the “Physicians Report”, the report indicated R1 was “unable to care for self” due to “Confusion.” It did indicate that R1 was able to bathe, dress, feed, and toilet themselves. However, it also indicated that R1 required “assistance”, and that that R1 was not able to transfer themselves to and from her bed, and that R1 was indeed “bedridden” due to both their “physical” and “mental” condition. It was also accurately indicated in R1’s “Physician’s Report,” that R1 indeed required “assistance” when it came to their ADL’s (Activities of Daily Living). The licensee stated that R1 arrived at the facility with no discharge papers or R1 medication orders signed by a doctor, so the licensee was unable to order any medication for R1. Licensee acknowledged the only documents she received for R1 prior to their arrival and admission at the facility was R1’s “Physician’s Report” and “list” of medications Therefore, based on the information obtained during the course of the investigation, the allegation of ‘Facility staff did not properly assess resident prior to admission’ is Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 29-AS-20250610125339

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(a)(c) · Plan of correction due date: May 29, 2026

Pre-Admission Appraisal (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (c) 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 in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Based on observation: The Licensee did not comply with this regulation as R1 was not propretly assessed and an Apparaisal was not conducted by the licensee to ensure that R1's needs could be met at the facility.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: The Licensee stated that they will conduct a pre-admission at all times. Licensee will review regulation for understanding and will email the LPA a letter self-certifing the understanding that they read the regulation and understand the importabce of conductuing the Pre-admission appraisal.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility to conduct an unannounced required annual visit. LPA was greeted by the Administrator. The Licensee, Nino Gelashvili and Administrator Gohar Ambartsumyan arrived shortly thereafter. LPA Urena explained the reason for the visit. The LPA and the Administrator 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. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Cameras were observed at the time of the visit. Smoke detector and carbon monoxide were tested and were operational at the time of the visit. The fire extinguisher was fully charged and last purchased on 10/15/2025. The licensee activated them at the time of the visit. The LPA observed required postings throughout the common space. KITCHEN: Knives are stored in a locked drawer next to the stove. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies were observed under the kitchen sink locked and inaccessible to residents in care. Hot water in the kitchen sink faucet measured at 115.8 degrees Fahrenheit (F). The laundry room is located next to the kitchen area. The side door leading to the hallway was observed to be unlocked at the time of the visit. Continues on LIC 809C... BEDROOMS: Had appropriate furnishings, and sufficient lighting. There are three residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. RESTROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured within the regulations. The hot water temperature was measured at 116.2 degrees Fahrenheit. OUTDOORS: There were no bodies of water noted. LPA observed a sufficient amount of space for activities. There was a detached garage located on site. LPA observed garage to store extra furniture and medical supplies at this time. RECORDS: Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. All files were in order. MEDICATIONS: Medications are centrally stored and locked in a cabinet in the laundry room area. medications are labeled and checked for expiration dates. The medications are documented properly on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Certificate of Liability of Insurance _ Emergency Drill Logs - Emergency Plan No citations were issued. Exit interview. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility to conduct an unannounced required annual visit. LPA was greeted by staff who called the Licensee and the Administrator. The Licensee, Nino Gelashvili and Administrator Gohar Ambartsumyan arrived shortly thereafter. LPA Urena explained the reason for the visit. The LPA and the Licensee 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. KITCHEN: Knives are stored in a locked drawer next to the stove. Kitchen appliances were in operable condition. The refrigerator and freezer need a thermometer to monitor the temperatures. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies were observed on top and under the kitchen sink unlocked and accessible to residents in care. Staff locked the cabinet door at the time of the visit. Hot water in the kitchen sink faucet measured at 115.8 degrees Fahrenheit (F). The LPA observed medications (insulin injections) located in the door area of the refrigerator and the freezer, and not locked in a secured box. The medications were accessible to residents in care and pose an immediate danger to residents in care. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Cameras were observed at the time of the visit; however, Licensee stated that they are not working at the moment. Smoke detector and carbon monoxide were tested at 12:10 p.m. and operational at the time of the visit. The fire extinguisher was fully charged and last purchased on 04/14/2024. Exits have functioning auditory devices, however, at the time of the visit they were not activated. The licensee activated them at the time of the visit. The LPA observed required postings throughout the common space, however the CCL poster, “If you see something, say something” poster was missing at the time of the visit. Licensee stated that one of the residents probably took it down. The Licensee post it in a location where it won’t be removed by residents in care. The laundry room is located next to the kitchen area. The side door leading to the hallway was observed to be unlocked at the time of the visit. Bedrooms: Had appropriate furnishings, and sufficient lighting. The LPA observed shared bedroom #4 to have a fireplace which had a cover and a painting in front of it. The LPA observed boxes of items stored in the corner of the room. The Licensee stated that staff are cleaning the garage, and they stored the boxes temporarily in the room. The LPA explained to the Licensee that the bedroom cannot be used for storage, even temporarily. The Licensee stated that they will remove the boxes as soon as possible. There was a linen closet in the hallway with extra towels and linens.RESTROOMS: The two (2) resident restrooms appeared clean and sanitary. The toilet in the hallway bathroom was not in operating condition at the time of the visit. The Licensee stated that the private bathroom in bedroom #4 had paper disposed in it, making the toilet in the hallway to get backed up, consequently the staff had to shut off the water in the toilet to prevent it from backing up. The toilet seat was observed to be loose, causing a potential hazard for the residents in care. The Licensee asked a handy person to fix the toilet while the LPA was conducting the annual inspection. At the time of the inspection the LPA did not observe a non-skid mat available in the tub. The Licensee stated that staff remove the mat when the residents are not being showered or given a bath. The private bathroom’s shower was observed to have a shower chair in disrepair, and in not useable condition. The Licensee stated that residents/staff do not use the shower seat, but that they had kept the seat to use as a sample to order a new shower chair, which they had already ordered. The LPA advised the Licensee to throw away the shower seat. The shower chair poses a potential hazard to residents in care. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured at 116.2 degrees Fahrenheit. OUTDOORS: The backyard has an outdoor area for residents’ use, however at the time of the visit the LPA observed the shaded area to be in disrepair due to the shade fabric (patio umbrella and canopy) being torn. The Licensee stated that the fabric was torn in the last few months. The LPA advised the Licensee to replace the shade items. The outdoor furniture was observed to be piled up together, preventing use of it. The licensee will work on the seating/shaded area to make it available for residents’ use. The facility has a side gate that self-latches with no obstructions in case of an emergency at this time. There were no bodies of water noted. LPA observed a sufficient amount of space for activities. There was a detached garage located on site. LPA observed garage to store extra furniture and medical supplies at this time. Emergency water was stored in the garage. RECORDS: Records review began at 1:05 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. All files were in order. MEDICATIONS: Medications are centrally stored and locked in a cabinet in the laundry room area, however at the time of the visit the LPA observed the medicine cabinet to be unlocked and accessible to residents in care. The Licensee stated that the key had broken inside the lock and the staff informed of the incident today in the morning. The Licensee stated that the lock will be replaced. Furthermore, the LPA observed a bottle of medication (Risperidone), the bottle contained two pills inside, located inside the laundry cabinet which was also unlocked. The LPA observed medications (insulin injections) located in the door area of the refrigerator and the freezer, and not locked in a secured box. The medications were accessible to residents in care and pose an immediate danger to residents in care. Medications review began at 2:29 p.m.; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. However, the LPA observed errors during the medication audit. The medication Trazodone (50mg./30 pills) was observed to have an inaccurate amount of pills, when compared to the Centrally Store and Destruction Record (LIC 622) information. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster-Licensee will add the name of the Clinic/physician for each resident in the list. - Certificate of Liability of Insurance (expired 04/01/2025), Licensee will email LPA a picture of a valid certificate. _ Emergency Drill Logs The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Citations were issued at this time. Exit interview. A copy of the report was issued, and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Apr 3, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility to conduct an unannounced required annual visit at 8:30 a.m. LPA was greeted by staff who called administrator. At 8:51 a.m. the Licensee, Nino Gelashvili and Administrator Gohar Ambartsumyan arrived. LPA explained the reason for the visit. Entranced interview conducted. At 9:15 a.m. the LPA 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. KITCHEN: The LPA began the inspection in the kitchen/food service area. Knives are stored in a locked drawer next to the oven. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies were observed under the kitchen sink locked and inaccessible to residents in care. Hot water in the kitchen sink faucet measured at 114.7 degrees Fahrenheit (F). COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Cameras were observed at the time of the visit however Licensee stated that they are not working at the moment. Smoke detector(s) and carbon monoxide detector were tested at 10:34 a.m. and operational at the time of the visit. The fire extinguisher was fully charged and last purchased on 04/14/2024. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. There is a separate laundry room, which is kept locked. Continued on LIC 809 Continued from LIC 809 BEDROOMS: The LPA observed four (4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There was a linen closet in the hallway with extra towels and linens. RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured and in compliance at the time of the visit between 105- and 120-degrees Fahrenheit. OUTDOORS: The backyard has a covered outdoor area equipped with furniture for resident use. The facility has two (2) side gates that self-latches with no obstructions in case of an emergency at this time. There were no bodies of water noted. LPA observed a sufficient amount of space for activities. There was a detached garage located on site. LPA observed garage to store extra furniture and medical supplies at this time, a fridge with extra food. Emergency water was stored next to the garage. RECORDS: Records review of resident files began at 9:44 a.m.; four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order. The LPA reviewed three (3) personnel files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were complete. The LPA also audited the current Administrator’s file, and it was in order. MEDICATIONS: Medications review began at 10:57 p.m. The medications are centrally stored and locked in a cabinet nextto the kitchen in the laundry area. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No deficiencies cited at this time. Exit interview. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 19, 2024