Sweet Home Senior Living 3

Allegation investigated: Staff due not ensure required posters are placed in the facility Staff do not ensure facility has scheduled activities for residents Facility does not ensure residents receive 3 meals per day Licensee does not ensure staff are able to communicate with residents Staff do not ensure residents are provided clean linens

Licensing Program Analyst (LPA) Quoc Huynh conducted an initial complaint visit fot the above allegations. LPA arrived at 10:04AM and met with the Licensee Lusine Srmikyan and Coordinating Manager (CM) Marine Bekyan and explained the reason for the visit. Entrance interview conducted. The LPA and Licensee conducted a safety check tour beginning at 11:50AM. No immediate concerns were observed. At 1:32PM, the LPA reviewed and obtained pertinent documents. Between 10:32AM and 1:58PM, the LPA interviewed two (2) residents, four (4) staff, and one (1) family member. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegations: “Staff due not ensure required posters are placed in the facility,” “Staff do not ensure facility has scheduled activities for residents,” “Facility does not ensure residents receive 3 meals per day,” “Licensee does not ensure staff are able to communicate with residents,” and “Staff do not ensure residents are provided clean linens.” It was reported that the facility staff removed state required postings off the walls. During the LPA’s tour of the facility, required postings were observed throughout the living room and were within the required dimensions per regulation. Interview with Resident #1 (R1) revealed that the required postings were allegedly taken down on 08/17/2025 and recently posted again. The LPA conducted an unannounced annual visit at the facility on 08/20/2025 and observed required postings at that time. Staff #1 (S1) confirmed that required postings remain on the walls in the living room and dining room. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. The facility allegedly advertised activities in their brochure, however, do not have any activities planned for the residents. During today’s visit, the LPA observed activity schedules posted throughout the facility in addition to activities conducted throughout the morning which consisted of music and dancing. Residents from the facility and subsequent facilities participated in the activity apart from residents who refused. Interview with four (4) staff and one (1) resident revealed that activities are scheduled every day between 11:30AM and 12:30PM with additional independent and optional group activities throughout the remainder of the day. Resident #2 (R2), S1, Staff #2 (S2), the CM, and the Licensee stated activities include but are not limited to music, dancing, physical exercise, puzzles, trivia, bingo, coloring, and cooking activities. The facility also works with a third-party vendor that provided two (2) activity directors that facilitate all activities for residents. Report Continued on LIC 9099-C R1 stated that today’s scheduled activity was trivia games, and they expressed that they did not observe any trivia games occurring. The LPA asked whether R1 goes outside to the shared courtyard between 11:30AM and 12:30PM to which R1 answered they do not, and they must have missed the activity. R1 expressed that they like to water plants and feed the squirrels and birds in the morning, which the facility encouraged, and the facility grounds contained various plants and fruit trees. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. It was reported that the facility only provided the residents two (2) meals a day which included breakfast and lunch at 3PM. The facility provided three (3) meals a day in addition to snacks in between each meal, per S2. S1 stated that meals are provided to residents who tend to sleep in or are unavailable during the scheduled mealtimes. Mealtimes are scheduled as follows: breakfast between 8AM and 9AM, lunch between 12PM and 1PM, and dinner between 4:30PM and 5PM. R2 confirmed the facility provided three (3) meals every day in addition to snacks and that staff accommodate to meal requests. Interview with R1 revealed that they are provided with breakfast and lunch, however, choose not to eat dinner because they are full from lunch. Additionally, R1 expressed they do not eat past 6PM due to scientific research theories. At 12:50PM, R1 was offered lunch and expressed that the food looked very good and that they have gained significant weight since residing at the facility. The Licensee shared that they grocery shop for all their facilities every other week and do not charge residents extra for ingredients for special meal requests. The CM reported that the facility also provided families who visit the facility meals during their visit and will typically send them home with food to go. The LPA observed sufficient food of good quality in the kitchen. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C It was alleged that facility staff do not speak English and cannot communicate with residents. Interview with staff revealed that most staff are fluent in English and there are a few who know basic English and can communicate well with the residents. The CM stood by during S2’s interview to assist with translation, however, S2 was able to communicate with the LPA in English and translation was not needed. S2 stated that they are typically paired with other staff that are fluent in English to utilize as a translator. They expressed that they know their residents very well and can meet their needs with no issues. S1 was fluent in English and expressed that all staff communication ranges from basic phrases to fluent. R2 expressed no issues in communication with staff. Witness #1 (W1) stated they regularly visit the facility and expressed no concerns about the facility and its staff and expressed gratitude to multiple staff. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. The facility allegedly did not provide clean linens to residents and did not change soiled sheets regularly. During the visit, the LPA observed all residents with clean linens and extra linens stored in each room. S1, S2, the CM, and the Licensee reported that linens are scheduled to be changed twice a week and if linens are observed to be dirty, staff will provide clean linens immediately. R1 reported they have not observed staff change their linens and was persistent on this notion due to their linens showing “the same wrinkles.” R2 stated their linens get changed regularly and has never had issues with having soiled linens. W1 stated they observe staff cleaning the facility often when they are visiting and have no concerns about the facility’s cleanliness. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 29-AS-20250828112436

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 12:50PM. The LPA met with the Coordinating Manager (CM) Marine Bekyan and informed them of the reason for the visit. Entrance interview conducted. Beginning at 12:55PM, the LPA and CM 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 a single-story residential home on shared property with other related facilities. The following was observed: COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Required postings were observed on the entryway wall. The facility maintained a comfortable temperature throughout the visit. Fire extinguishers were observed throughout the facility and were last serviced on 04/16/2025. KITCHEN: The LPA observed knives stored inaccessible in a locked drawer near the sink. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food and water stored in the office. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. Grocery shopping occurs every two (2) weeks, sometimes more when needed. The kitchen also contained centrally stored medications and employee files that were secured. Report Continued on LIC 809-C BEDROOMS/RESTROOMS: There were three (3) total bedrooms: each bedroom approved for dual occupancy with Bedroom #3 utilized as a private room at this time. Bedroom #1 had a direct exit to the outside and was approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens and supplies are stored in each Bedroom in addition to the office. There were two (2) total restrooms in the facility, both shared resident restrooms located in the front and rear hallways. The front hallway restroom contained laundry machines that were observed to be in good condition. Locked cabinets contained cleaning supplies and laundry detergent. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 107.8 degrees F and 109.6 degrees F which is within the required range per regulation. OUTDOOR AREA: The surrounding grounds had multiple shaded patio areas equipped with furniture in good condition for resident and visitor use. The front yard had a driveway with a remote operated gate as well as a door for everyday use. There was one (1) emergency exit door located on one side of the facility that led to the front yard. Exits and passageways were free of obstruction. The facility had additional gates with access to the neighboring three (3) facilities that the Licensee also operates. MEDICATIONS: Medication review began at 1:09PM. Medications were centrally stored and kept inaccessible in the kitchen. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Report Continued on LIC 809-C RECORDS: Record review began at 1:40PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and 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 training. All records were in order. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 06/05/2025. Smoke and carbon monoxide detectors as well as fire doors were tested at 1:26PM and were operational. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 20, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:10 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with LUSIER SRMIKYAN, licensee / Administrator and BEKYAN MARINE, coordinator / manager and explained the reason for the visit. 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. Pertinent documents were obtained including LIC 500, LIC 9020A, LIC 610D, and a copy of current liability insurance. KITCHEN: The LPA inspected the kitchen/food service area at 9:26 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 109 degrees Fahrenheit at 9:32 a.m. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 9:51 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/15/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 6/21/2024 and conducted quarterly. Activities were observed in the common areas. Report Continued on LIC 809C... Report Continued from LIC 809... RESTROOMS: The two (2) resident restrooms one (1) designated as a shared restroom and one (1) designated as a private bathroom. Both were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 10:02 a.m.-10:15a.m; the first, shared bathroom measured at 106.9 degrees Fahrenheit and the second, private bathroom measured at 108.6 degrees Fahrenheit, both within the required range. BEDROOMS: There are three (3) total bedrooms in the facility; two (2) are designated as a shared room, one (1) is designated as private resident room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. GARAGE/OUTDOOR: The garage is maintained locked at all times and designated as the facilities office. There is a washer and dryer on premises. LPA observed an adequate amount of emergency food and water supply at 9:55 a.m. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The outdoor area has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPAs observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. RECORDS: Resident Records were reviewed beginning at 10:18 a.m. and personnel records at 11:30 a.m. five (5) out of five (5) 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. Four (4) 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 with required forms observed complete and updated. INTERVIEWS: Three (3) staff interviews were conducted. Staff are knowledgeable of their responsibilities. Two (2) resident interviews were conducted. No concerns noted at the time of the visit. MEDICATIONS: Medications review began at approximately 12:22 p.m. Medications and first aid kits are located in a locked kitchen cabinet. Medications for five (5) out of five (5) residents were reviewed. Medications reviewed were found to be administered as prescribed and documented on the centrally stored medication and destruction records. No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 30, 2024