Saint Mariam Senior Care

Type of visit: Required - 1 Year

On 5/7/2026 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct the required Annual Inspection. Upon arrival, LPA was greeted by the Staff, who granted access to the facility. LPA explained the reason for the visit. LPA Khurshudyan reviewed the required postings posted on the entrance wall and throughout the facility. Administrative Assistant Viktorya Hayrapetyan arrived shortly after. At approximately 10:05am LPA requested staff and residents’ rosters for review. The inspection tool was used to complete the visit. At 10:35pm LPA, with the help of the Staff, began a physical plant tour of the facility and the following was observed: This is a single-story building with four (4) bedrooms, and all rooms are designated for residents’ use only. There are three (3) bathrooms, a kitchen, common areas: living and dining rooms, and an outdoor area. Facility has an approved fire clearance for six (6) non-ambulatory residents, all of which one (1) may be bedridden for bedroom #4, and a Hospice waiver approval for six (6) residents. Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. No expired food was observed. Facility stores knives and sharps inside the locked kitchen cabinet. Sufficient amount of emergency supply of food / water was readily available inside the kitchen cabinet. Food storage and preparation areas are clean and inaccessible to pests. LPA observed one (1) fire extinguisher located on the kitchen wall. The fire extinguisher was last serviced on 6/13/2025. Dish soap and other chemicals were observed to be stored under the sink inside the locked cabinet and inaccessible to residents in care. Continue on LIC809-C Bedrooms: LPA observed bedrooms to be properly furnished with beds, linens, nightstands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean. Residents have enough personal hygiene products. During the visit, the LPA observed that a bedridden resident is occupying bedroom #3; however, according to the approved fire clearance, the resident must be inside bedroom #4. Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits at the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:05am, LPA measured the room temperature to be 73 degrees Fahrenheit. There is a linen closet with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards found inside the facility. Facility has landline, LPA checked it was operational. Bathroom: The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. The hot water temperature was measured at approximately 11:15am to be 117.1 degrees Fahrenheit. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared. LPA observed non-skid mats and grab bars inside the bathrooms. Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by staff at approximately 11:35am and were observed to be operational. Garage: There is no garage in the property. Laundry Room: Functioning washer and dryer is located in the separate laundry area next to the kitchen. Laundry detergents and other chemical supplies observed locked inside the laundry room cabinet. Backyard/Front yard: LPA observed sufficient yard space and fenced backyard with appropriately covered shaded area available for residents to rest. There is outdoor furniture under the shaded area. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. During the physical walk through LPA observed all exit areas to be free of clutter and obstruction. There is no body of water. Staff/Client File review: Facility records are kept inside the locked commercial/metal cabinet located in the living room. Between 12:30pm -1:35pm LPA conducted records review of six (6) staff files and four (4) residents’ records. Files were complete and updated. Continue On LIC809C Medications: At approximately 1:30pm, LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. LPA observed centrally stored medications locked inside the cabinet located in the living room and inaccessible to residents in care. Complete First-aid kit is available and is placed next to the entrance door . No potentially dangerous items were found in the facility. The facility operates with two-three (2-3) shifts and has one to two (1-2) staff members for each shift. LPA conducted interviews with the Administrative Assistance, two caregivers and two (2) out of four (4) residents who were able to communicate and answer questions. Facility plan/sketch is posted on the wall along with other posting requirements. LPA collected LIC500, LIC9020, and copy of Liability Insurance, and copy of Administrator certificate at the time of the visit. LPA also checked the Emergency Disaster Form and informed the facility to update the form and send the new copy to LPA. The Administrator certificate will be expiring on 8/17/2026. The Liability Insurance expires 4/30/2027. The facility has no outstanding balance of licensing fees. A Deficiency issued during today’s visit. See LIC809-D Exit interview conducted, a copy of this report signed, appeal rights explained and delivered.the state’s words, verbatim · CDSS document, May 7, 2026

Type of visit: Required - 1 Year

On 02/04/25, at 9:35am, Licensing Program Analyst (LPA), Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Caregiver Diana Lalaianand disclosed the purpose of the visit. The administrator, Marina Zhigoyan was advised of the visit and arrived about forty (40) minutes later. LPA asked for the census, resident, and staff files. A physical tour was conducted at 11:30 AM and observed the following: Facility is a single-story home: The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. There is one (1) fire extinguisher that is located on your right-hand side of the kitchen against the wall with an expiration date of 03/2025. There is a telephone line on the counter in the kitchen. There is extra, food in the kitchen pantries. The knives are kept in two (2) top drawers of the kitchen counter one (1) on your right-side and one (1) on your left-side in a locked and inaccessible to the residents. The resident/staff files are be kept in a tall, black cabinet along with the medication/first aid cabinet locked, secured and inaccessible to the residents by the entrance of the facility. Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does have a signal system. The facility does not have a pool/body of water. There is no garage. LIC 809C-continued Bedrooms: There is a total of four (4) bedrooms and three (3) bathrooms. One (1) of the bedrooms has a private bathroom. Three (3) bedrooms are shared and one (1) bedroom is single occupied. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 110-111 degree Fahrenheit. There is three (3) pantries in the hallways that have extra linen. There is one (1) washer and dryer that is located near the kitchen area and have the chemicals in the above cabinets locked and inaccessible to the residents. The dining/living room area has enough seating for the residents and the staff with a large television. The furniture is in good condition. There is a fire place that has a black covering inaccessible to the residents. This is where the staff/resident files are kept and the medication cabinet. The house temperature is at 73-degree Fahrenheit. The smoke detector/carbon monoxide is in the hallway and is operable. Administration: These signs are located at the entrance of the facility: Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Residential Infection plan, Personal Rights of Residents, Rights of Resident by Council, Family Council, Ombudsman, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy, Disaster Plan and YES. The insurance expires 04/2025. An exit interview was conducted, no citation(s) were issued, and a copy of this report was issued.the state’s words, verbatim · CDSS document, Feb 4, 2025

Allegation investigated: Staff pushed a resident in care Staff yells at the residents in care

On 07/23/24, at 9:05am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administator, Viktorya Hayrapetyan. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 07/16/2024, Licensing Program Analyst (LPA) Gina Saucedo initiated the complaint investigation. On 07/23/24, LPA Saucedo asked for the census, staff, and resident files. On 07/23/24, LPA Saucedo interviewed additional staff conducted a physical tour, gathered additional information, and delivered findings. 9099C-continued Unsubstantiated Regarding the allegation: Staff pushed a resident in care. It is being alleged that one (1) of the residents suspects that a nurse pushed their wheelchair from behind as they were going down the ramp that goes outside, causing them to put their hand out to catch themselves. LPA interviewed four (4) out of six (6) residents that confirmed that they have never been pushed while in care. Resident #1 (R1) was able to confirm that they had fallen on their own. Three (3) out of three (3) staff confirmed that R1 did fall while going down the ramp. Staff also reported that R1 does not like to wait for staff for help. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff yells at the residents in care. It is being alleged that there are staff at the facility that yell at residents. Although, resident #1 (R1) did confirm that the staff are loud, they did not confirm that staff yell at them. LPA interviewed four (4) out of six (6) residents of which three (3) residents confirmed that staff do not yell at them. Three (3) out of three (3) staff confirmed that they do not yell at residents. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator. Regarding the allegation: Staff did not provide assistance to a resident in care. It is being alleged that resident #1 (R1) fell on the floor and was left there overnight. Three (3) out of three (3) staff did confirm that R1 continues to fall because they need assistance. Three (3) out of three (3) staff did state R1 needs a minimum of two (2) people to move them around. LPA interviewed four (4) out of six (6) residents that confirmed that they do need assistance and have no way of getting assistance when needed. LPA observed that six (6) out of six (6) residents do require specific assistance according to their file review which is not being met according to their individual needs. Therefore, based on the LPA's observations, record review, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time. An exit interview was conducted, a citation(s) was issued for the above allegation(s), Appeal rights and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 31-AS-20240711170640

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 24, 2024

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities:(a) ...Personal Rights of Residents... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4)To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not provide assistance to a resident in care regarding their individual needs which poses an Immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Licensee/Adminstrator is to provide training to all staff to identify individual needs of residents. POC 07/24/24

Type of visit: Case Management - Deficiencies

On 07/23/24, Licensing Program Analyst (LPA) Gina Saucedo, conducted unannounced, subsequent visit to this facility in conjunction with a complaint control #31-AS-20240711170640. LPA met with the Administrator, Viktorya Hayrapetyan and explained the reason for the visit. During the physical tour, LPA Saucedo witnessed an empty bed with a staff's belongings on it and asked the resident who was sleeping on that bed. The resident stated that it was a staff that had slept there the night before. LPA Saucedo took a picture of the staff's belongings. During the physical tour, LPA conducted a review of records and no incident report was sent to Community Care Licensing Departmen-(CCLD) for the multiple times that resident #1 (R1) had fallen in the facility. In addition, a death report was not sent to CCLD regarding a previous hospice resident that had passed away. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Jul 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jul 24, 2024

87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure multiple reports to be submitted to CCLD from the above facility involving multiple incidents which poses an Immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: An Unusual Report is to be sent to Community Care Licensing Department within seven (7) days regarding a death report and resident injuries while in care. POC 07/24/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(a) · Plan of correction due date: Jul 24, 2024

87307(a) Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not provide comfortable living accommocations and privacy to the staff/resident which poses an Immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: The licensee/admnistrator shall remove the staff bed immediately whom is sharing a room with one (1) of the residents. The licensee/administrator shall send a picture of the bed removal. POC 07/24/24

Type of visit: Prelicensing

On 04/08/24, at 10:05am, Licensing Program Analyst (LPA), Gina Saucedo, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Division-CCLD on 02/01/2024, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The requested capacity is for five (5) non-ambulatory and one (1) bedridden, total of up to six (6) residents but fire clearance only designated room # four (4) for bedridden use. Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant at 10:25 AM inside and outside and observed the following: Bedrooms Staff: There is no bedroom designated for staff. Bedrooms Residents: There is a total of four (4) bedrooms. There shall be no more than two (2) clients per bedroom if used for non-ambulatory. Only one (1) is cleared for bedridden which is bedroom # 4 (four). There is three (3) other bedrooms in the house. One (1) of the bedrooms, bedroom # three (3) has a private bathroom. There are two (2) other bathrooms which proper grab bars and non-skid mats. All the bedrooms have proper bedding, chairs, nightstands, lamps in addition to overhead lighting. LIC 809C-continued The dining/living room Resident & Staff Files: There is enough seating for staff and residents. The furniture is in good condition. The resident/staff files will be kept in a tall, black cabinet along with the medication/first aid cabinet locked, secured and inaccessible to the residents. Linens & Hygiene Supplies: Adequate supply of linen stored in one (1) of the cabinets in the bathrooms and in one (1) of the pantries in the hallway. Emergency Phone Numbers, Exit Plan & Menu: The facility has a working phone number land line on the kitchen counter. Fire Extinguisher located in the kitchen on your right-hand side mounted on the wall. It is fully charged and has a date of 03/01/24. Food Service: Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored on your left-side of the kitchen locked and secured inaccessible to the residents two. Food supply adequate stored in several cabinets and consists of the following: canned goods, bottles of water, cereal, emergency buckets. The refrigerator, stove and microwave are in good condition and working. Smoke Detectors: There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected with the doors for an emergency. Water Temperature: The water temperature was tested for the bathrooms are they are within regulation:115.-116 Fahrenheit. LIC 809C-continued Pool/Jacuzzi: There is no pool/jacuzzi in the facility. Fire clearance: Fire Clearance was approved on 03/11/2024 signed and dated. Signal system: The facility does have a signal system installed. Administration: The facility had submitted a Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan. These signs are located at the entrance of the facility: Personal Rights of Residents, Rights of Resident by Council, Family Council, Infection Control, Emergency and Disaster Plan, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy and YES. The Component III Orientation RCFE was shown to the Administrator. Structure: Overall Facility is a four (4) bedroom home with three (3) bathrooms, single-story home with two (2) outside ramps, there is no garage. The home does not have a fireplace which is covered in the dining area. There is one (1) washer and dryer located in the hallway which is locked and inaccessible to the residents. There are chemicals above the cabinets where the washer and dryer are located which are also locked, secured and inaccessible to the residents. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview conducted and copy of this report issued to the administrator.the state’s words, verbatim · CDSS document, Apr 8, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Capacity: 6 Census (if any clients in care): 0 COMP II Participants: VIKTORYA HAYRAPETYAN, MARINA ZHIGOYAN Interview Method: Telephone interview On March 25, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 25, 2024