St. John of Kronstadt Home

Type of visit: Required - 1 Year

(PAGE 1) Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. Upon arrival LPA was greeted by staff and explained the reason for the visit and to call their Administrator. LPA met with Liana Vertelkina, Administrator who arrived shortly after. The reason for the visit was explained. The LPA and 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. The facility is licensed to serve 21 ambulatory only, residents over the age of 60. The facility is located in a residential area and consist of a one story building with 19 resident rooms/with bathrooms, a recreation room, kitchen, dining area, laundry room, medication room, 3 storage rooms, 3 community showers, office, staff restroom and visitor restroom and outside shaded patio. COMMON AREAS: This includes the recreation room, and dining area. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguisher was observed and fully charged on 08/26/2025. The facility's smoke alarms are hard wired, and the facility is equipped with sprinkler system. Fire alarm/sprinkler system was last tested on 08/05/2025 and was found to be in compliance with Fire Code Regulations at the time of inspection. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/24/2025 and are conducted quarterly. Activities were observed in the common areas. There is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability.Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... INTERVIEWS: Starting at 9:08 a.m. and throughout the visit three (3) staff including the Administrator and six (6) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. KITCHEN: The LPA inspected the kitchen/food service area at 10:32 a.m. the kitchen appeared clean and appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. LPA observed emergency food and water. LAUNDRY ROOM : LPA observed the locked laundry room adjacent to the kitchen. Laundry room has a washer and dryer and locked cleaning supplies. SUPPLY CLOSET: LPA observed two (2) locked supply closets containing chemicals, cleaning supplies, and emergency supplies including Personal Protective Equipment (PPE). BEDROOMS: LPA observed seven (7) randomly selected resident bedrooms, 103, 105, 109, 111, 119, 123 and 125. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. RESTROOMS: Seven (7) resident restrooms and three (3) community showers appeared clean and observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels ; towels and washcloths are not shared in the private rooms. The hot water measured between 107.2 – 118.6 degrees Fahrenheit all within the required range. SURROUNDING GROUNDS (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Resident Records were reviewed beginning at 11:08 a.m. Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 12:01 p.m. Six (6) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control plan, practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. MEDICATION AUDIT: LPA conducted a medication review on six (6) randomly selected residents at approx. 1:00 p.m., The medications are centrally stored in the medication room adjacent to the Administrators office. The medication room remains locked at all times. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. During the review LPA observed resident medications to be pre-sorted two (2) days in advance. Administrator was made aware that medication cannot be pre-sorted and of the potential health and safety risk. At the time of the visit the Administrator provided a written statement indicated and confirming their understanding of this regulation, 87465(h)(5) and their intent to abide by it. Administrator will speak to staff about the importance of not pre-sorting medications along with providing a signed statement from all staff. Plan of correction cleared on site. DOCUMENTS: Documents obtained during the visit include: LIC 9020A- Resident roster and copy of the Limited Liability insurance. LPA also reviewed the staff roster and schedule. 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. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Hrpsime Avalyan and explained the reason for the visit. The facility is licensed to serve 21 ambulatory only, residents over the age of 60. The facility is located in a residential area and consist of a one story building with 19 resident rooms/with bathrooms, a recreation room, kitchen, dining area, laundry room, medication room, 3 storage rooms, 3 community showers, office, staff restroom and visitor restroom and outside shaded patio. LPA toured the facility with Vita Kravchenko - Staff and observed the following: Facility is clean and in good repair inside and outside. Kitchen was observed and sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were stored. Sharps are stored in the kitchen. Cleaning supplies are stored in storage areas. All common areas have sufficient seating furniture and in good repair. LPA randomly choose 5 resident rooms and observed each has the required furniture, sufficient bedding, and lighting. Water temperature was tested in the bathroom's between 113.7-114.8 degrees F., which is within the required 105-120 degrees F. Common showers were observed and each has the required grab bars and skid mat/strips. The building has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 9/20/23. No large bodies of water were observed. Passageways were clear of obstructions. LPA reviewed medication and files for 5 residents, and 5 staff files and interviewed 3 staff and 3 residents. LPA reviewed Infection Control Plan and Emergency Disaster Plan. No deficiencies were noted during this visit. Exit interview was conducted with Liana Vertelkina and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alma Gonzalez conducted the required annual inspection. LPA met with Administrator Liana Vertelkina and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs (SHN). During the visit LPA observed the following: Infection Control: The facility is using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (21) ambulatory residents age 60 and above. Last Fire Drill was conducted 09/16/23. Staff are adhering to operational requirements. Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. (See LIC809C for the continuation of this report) Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and Staff 1 (S1) - Staff 2 (S2). Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator certificate expired 4/05/2023. Administrator stated the renewal documents were submitted to the recertification unit but an Administrator Certificate has not been received yet. Proof of document submittal was provided. Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents. Resident Records-Incident Reports: LPA reviewed Resident files for R1 2. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Physical Plant & Environment Safety: LPA conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The physical plant tour was conducted with the assistance of Administrator Liana Vertelkina. The physical plant consists of a single story building with 19 resident bedrooms which consist of 18 single and 1 shared room, each bedroom has a sink and toilet. There is a recreation room, Kitchen, Dining hall, laundry room, medication room, 3 storage rooms, 3 baths and 1 shower, Office, Staff restroom, visitor restroom and outside shaded patio. Resident rooms were randomly chosen for inspection and LPA observed that resident bedrooms have the required furniture, bed linens, sufficient lighting and closet/drawer space to accommodate each resident comfortably. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures and have secure grab bars, showers were free of mold/ mildew and non-skid mats or strips were properly in place. Hygiene supplies are provided. Water temperature was measured and temperature measured 116 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. Refer to LIC 809C for the continuation of this report Planned Activities: Calendars and supplies for activities were observed. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Additional food supply and disaster food supply was also observed. The food is properly stored in the refrigerator(s). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining room has adequate seating. Posted menu observed. Health Related Services/Incidental Medical Services: The medications are centrally stored in a room by the office. Medication room is locked and inaccessible to facility residents. Medication was observed to be in bubble packs and/or original containers. LPA reviewed medication for R1-2. The facility uses the Medication Administration Records (MARs) to document medications given to residents. Medications are administered as prescribed by the Physician. Per Title 22 Regulations, there were no deficiencies observed during visit. Exit interview and a copy of this report was provided to Administrator Liana Vertelkina.the state’s words, verbatim · CDSS document, Oct 2, 2023