Safeway Senior Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with licensee, Anna Sargysyan, and was explained the reason for the visit. At 8:49 AM, with the assistance of licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 11:08 AM, the smoke alarms were tested and they are operational, alarms are located in each bedroom, the hallway, and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 4.22.2026. During the visit the facility is at 76 degrees Fahrenheit. The facility is fire cleared for three (03) non-ambulatory residents. One (1) bedridden in bedroom 2 or 3. Ambulatory only in bedroom #1, 4 or 5. Hospice waiver for six (6). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen cabinet below the sink. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedroom #1, and bedroom #5 are private. Bedroom #2 (single occupant) and bedroom #4 are shared. Bedroom #3 is vacant. Continue to LIC 809-C all of the bedrooms that are in used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bathrooms: There are three (3) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.2 degrees Fahrenheit for bathroom #1 located in the hallway in between bedroom #2 and bedroom #3. Bathroom #2 is by the facility entrance. Hot water temperature was measured at 105.8 degrees Fahrenheit for bathroom #2. Hot water temperature was measured at 105.4 degrees Fahrenheit for bathroom #3, located inside bedroom #1. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Office space is beside the dining table. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. Garage is attached and is use for storage. 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. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. Medications: LPA observed that the medication are kept in the living room in a locked cabinet and inaccessible to residents in care. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: Planned activities are offered. LPA reviewed residents records and LPA found all files to be complete. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued.the state’s words, verbatim · CDSS document, Jun 2, 2026

Allegation investigated: Staff did not notify resident's DPOA of medication changes Staff inappropriately placed resident on hospice without DPOA's consent

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Anna Sargsyan and explained the reason for the visit. --- Staff did not notify resident's DPOA of medication changes It was alleged that R1’s medications had been adjusted without the DPOA's knowledge. To investigate the allegation on May, 4 2026, LPA requested documents at around 9:30a.m. and interviewed one (1) staff from 10:30a.m. to 11:30a.m. A review of R1’s file revealed that the Responsible Party has Durable Power of Attorney for property only. LPA did not observe Medical Power of Attorney in the file. A review of the Medication Administration Records agrees with the Physician’s Orders. During interviews, staff stated they give all medications as prescribed by the physician. (CONT on LIC9099-C) Unsubstantiated Staff added they were in constant communication with the responsible party regarding R1’s care and received many letters of thanks and praise. Based on interviews and record review, there is not enough information to verify the above allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff inappropriately placed resident on hospice without DPOA's consent It was alleged that Responsible Party (RP) found out this week that facility had put Resident #1 (R1) on hospice twice without notifying them or giving a reason. To investigate the allegation on May, 4 2026, LPA requested documents at around 9:30a.m. and interviewed one (1) staff from 10:30a.m. to 11:30a.m. A review of R1’s Hospice Care and Palliative Care records revealed that they were both signed by R1’s DPOA. During interview, staff stated R1’s responsible party has always been notified and involved with everything regarding R1’s care. Staff added that both documents were signed by the DPOA. Based on interviews and record review, 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, May 4, 2026 · control 31-AS-20260428125905

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda delivered, in person, an amended LIC 9099 and LIC 9099-C complaint investigation report in association with complaint report# 31-AS-20250128092923 the initial complaint investigation visit conducted on 1.06.2025 The Amended LIC 9099 and LIC 9099-C Complaint Investigation Report was hand delivered to licensee, Anna Sargsyan.the state’s words, verbatim · CDSS document, May 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. At 11 AM Anna Sargysyan, who is the licensee met with LPA, explained the reason for the visit. At 11:21 AM, with the assistance of licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 2:15PM, the smoke alarms were tested and they are operational, alarms are located in each bedroom, the hallway, and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 5.5.2025. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for three (03) non-ambulatory residents. One (1) bedridden in bedroom 2 or 3. Ambulatory only in bedroom #1. Hospice waiver for six (6). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen cabinet below the sink. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedroom #1, bedroom #2, bedroom #3, and bedroom #5 are private, but bedroom #2 and bedroom #5 are vacant. Continue to LIC 809-C Bedroom #4 is shared, all of the bedrooms that are in used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bathrooms: There are three (3) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.9 degrees Fahrenheit for bathroom #1 located in the hallway in between bedroom #2 and bedroom #3. Bathroom #2 is by the facility entrance. Hot water temperature was measured at 105.8 degrees Fahrenheit for bathroom #2. Hot water temperature was measured at 105.9 degrees Fahrenheit for bathroom #3, located inside bedroom #1. There was enough clean linen available in the cabinets in the laundry room. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or bodies of water. The garage is attaches and is used for storage. Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located in the locked garage. 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. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Office is located by the living room. Continue to LIC 809-C Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisal. Planned activities are offered. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.the state’s words, verbatim · CDSS document, May 5, 2025

Allegation investigated: Staff did not assist resident with medication management needs. Staff did not assist resident with mobility needs.

This is an amendment to the original report issued on 1.06.2025. Additional information was added to clarify the investigation. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an initial complaint visit to the facility to investigate the above allegations. LPA met with Administrator Anna Sargsyan and advised her of the visit. An entrance interview was conducted. At 12:02 pm LPA conducted a physical plant tour to ensure the health and safety of the residents in care. At 12:45 pm LPA initiated resident interviews. File reviews were attempted. LPA requested the following documents which include but not limited to the centrally stored medications and destruction record, resident appraisals, physician’s reports, and staff medications training. Per the Administrator there were no resident files and no documented medications training for staff that assist with medications. Allegation #1: Staff did not assist resident with medication management needs. Continue to LIC 9099-C Substantiated It was alleged that the facility staff did not dispense three (3) medications for resident #1 (R1). Investigation revealed that during medications review there was no resident file including the Centrally Stored Medication and Destruction Record (CSMDR) for R1 or any residents. LPA conducted a sample of three (3) resident medications and observed that one (1) out of three (3) medications were not issued as prescribed. R1 was not assisted with their prescribed medication for nine (9) days from the month of December when R1 was first admitted 12.24.2024. Three (3) out of eight (8) medication were observed for R1. At 12pm LPA interviewed staff #1 (S1) who stated staff #2 (S2) and staff #3 (S3) assist residents with their medications. S2 stated that they follow medication as prescribed. When asked why R1 missed nine (9) days of medication staff declined to say anything and just stared at LPA. LPA requested medications training, however there was no documented training provided. LPA review the facility’s medications policy which state that the licensee will have "A record of currently prescribed medications, and an indication of whether the medication should be centrally stored." At 12:45 PM-1:10PM, LPA interview three (3) out of five (5) residents who were able to communicate. Interview revealed R1 and R3 are not aware of the medications they are taking and dispense time varies. Based on record review and interview obtained the allegation is SUBSTANTIATED. R1 was not assisted with medications for 9 days. Deficiency issued. Allegation #2: Staff did not assist resident with mobility needs. It was being alleged that facility staff does not assist residents with mobility needs. To investigate this allegation, LPA conducted a file for R1. LPA attempted to reviewed R1’s Admissions Agreement, Physicians report and Appraisal, however the Administrator had no records on file for any residents. There was no documented care plan to determine the residents needs and there was no documented training for staff related to any of the resident’s care. LPA interviewed the Administrator and one (1) staff out of three (3). Staff interview revealed that R1 is bedridden and no assistance with mobility is provided. R1 is provided meals, room and board, medication assistance, and assistance with ADL's in their room. R1 is not assisted out of their bed to join other residents for dinner and or other activities. In addition, during interviews with other residents, it was determined that staff are not consistent with their assistance. Two (2) out of five (5) residents state that staff are not consistent in providing the following assistance of ADL's and medication management. During the visit LPA observed R1 staying at their room the whole time without any rotation or staff observation. Based on observations, and interviews, the allegation is SUBSTANTIATED. Deficiency issued. Appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Jan 6, 2025 · control 31-AS-20241230165721

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 22, 2025

Incidental Medical and Dental Care Services. Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. LPA observed that R1 medication has, discrepancies. This requirement is not met as evidenced by: Based on observation, residents medication bubble pack was full and unuse which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: The Administrator has agreed to the following: Administrator and staff will take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name. date of schedule. Upon completion submit the training material and staff sign in sheet.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Jan 20, 2025

Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety... This requirement was not met, evidenced by, based on interviews, staff are inconsistance to provide assiatance to the residents. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: The Administrator has agreed to the following: All administrator and staff will take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name. date of schedule. Upon completion submit the training material and staff sign in sheet.

Type of visit: Case Management - Deficiencies

On 1.6.2025 in conjunction with an initial complaint visit control number 31-AS-20241230165721. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda completed an unannounced CASE MANAGEMENT- Deficiencies visit. LPA met with Licensee Anna Sargsyan, explained the purpose of the visit. During the facility tour at 12:02 PM . LPA observe the following: No files for employee and administrator to review. Two (2) staff are not associated or cleared to be with the facility. Five (5) residents does not have a file to review (Admission agreement; needs and service plan; physician report). Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency and civil penalty was observed and cited (Refer to LIC 809-D). Copy of this report provided, appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Jan 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jan 20, 2025

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidenced by: Based on observation, administrator and staff needs training which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: Licensee will conduct a training for themselves and staff and submit attendance sheet by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(c) · Plan of correction due date: Jan 13, 2025

Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled. This requirement is not met as evidenced by: Based on observation, administrator did not provide admission agreement upon taking in a resident which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: Licensee agree to provide admission agreement to everyone.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(b) · Plan of correction due date: Jan 13, 2025

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 licensing agency staff. ach resident’s record shall contain at least the following information: Name; DOB, SSN, physician information, etc. This requirement is not met as evidenced by: Based on record review, administrator did not provide five (5) residents records to LPA which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: Administartor agrees to have all the necessary paperwork done when onboarding residents to the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 873511(a) · Plan of correction due date: Jan 7, 2025

A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182 This requirement is not met as evidenced by: Based on record review, licensee did not ensure that S2 and S3 is associated at this facility which poses an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: Administrator will send proof of association or will send an association documents for S2 and S3 to CCL on or before the POC date, if unable to log in at Guardian.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted pre-licensing required visit and inspection of the facility. At 9:45 AM Anna Sarkisyan who is the licensee met with LPA, explained the reason for the visit. At 10:00 am, with the assistance of licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 12/9/2023. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for three (3) non-ambulatory residents; two (2) ambulatory; (1) bedridden; bedroom #2 or bedroom #3 for non-ambulatory and bedridden; bedroom #1, bedroom #4 and bedroom #5 are cleared for ambulatory. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the garage. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedroom #1, bedroom #2, Bedroom #3, and bedroom #5 are private. Bedroom #4 is for shared use. All of the bedrooms are going to be used by residents, all of the bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C BATHROOMS: LPA observed three (3) bathrooms that are clean and in good repair. All of the bathrooms are properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured between 112.2°F. observed appropriate grab bar and had non-skid mat. Bathroom #1 is located inside bedroom #1. Bathroom #2 is located inside in the hallway in between bedroom #2 and bedroom #3. Hot water for bathroom #2 measured at 109.9°F. Bathroom #3 is located in the hallway. Hot water for bathroom #3 measured at 109.2°F. COMMON AREAS: The facility maintains a comfortable temperature at 73°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Office is located by the dining area. MEDICATION: The medications will be kept in the kitchen cabinet and the team observed the cabinet to be kept locked and inaccessible to residents in care. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:20 AM they were tested and observed to be operational. SURROUNDING GROUNDS: The backyard of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is walled up. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water. The driveway, passageway and entrance to the home was clear of obstructions. All entry and exit doors have a functional auditory alert when the doors open. GARAGE: Garage is attached and accessible only through the lock door beside the kitchen. The washer and dryer appear to be in good condition. Laundry supplies are kept lock and inaccessible when not in use with supervision. Component III was conducted with the administrator and licensee. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved. Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.the state’s words, verbatim · CDSS document, May 1, 2024