Sweet Home Senior Living Facility

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 11:25AM. The LPA met with the Licensee Lusine Smrkiyan and Coordinating Manager (CM) Marine Bekyan and informed them of the reason for the visit. Entrance interview conducted. Beginning at 11:43AM, the LPA and 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. The facility is a single-story residential home on shared property with other related facilities. The following was observed: 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 (1) side of the facility that led to the front yard. Exits and passageways were free of obstructions. The facility had additional gates with access to the neighboring three (3) facilities that the Licensee also operates. 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. Nightlights were observed throughout the hallways. There was a closet located in the hallway which contained laundry machines in operating condition and extra supplies of linens. Report Continued on LIC 809-C KITCHEN: The LPA observed knives and medications stored inaccessible in a locked drawer and cleaning supplies secured under the sink. An additional supply of medications and files were also secured in a cabinet. 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. BEDROOMS/RESTROOMS: There were four (4) total bedrooms: two (2) shared and two (2) private. Bedroom #3 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. There were three (3) total restrooms in the facility: two (2) private and one (1) shared. 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. Hygiene products were secured in each restroom. Hot water was tested and measured between 110.1 degrees F and 115.2 degrees F which is within the required range per regulation. MEDICATIONS: Medication review began at 11:57AM. 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. RECORDS: Record review began at 12:47PM. 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. Report Continued on LIC 809-C 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. Fire extinguishers were observed throughout the facility and were last serviced on 05/16/2025. Emergency disaster drills are conducted quarterly, with the last documented drill on 12/20/2025. Smoke and carbon monoxide detectors as well as fire doors were tested at 11:55AM 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, Jan 7, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit. At 1:00 p.m., the LPA met with staff and explained the reason for the visit. LPA met with Administrator Marine Bekyan and the reason for the visit was explained. Licensee representative, Lusine Srmikyan arrived later during the visit. At 1:08 p.m., the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. At 1:14 p.m., hot water measured at 108.9-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen drawer. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and three (3) bathrooms for resident's use. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 1:19 p.m., hot water measured between 108.3 and 109.8-degree Fahrenheit all within the required range. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout bathrooms and facility to promote hand washing. DOCUMENTS: LPA obtained the following documents, LIC 9020 Resident roster, LIC 500 Personnel report, and current liability insurance. Report continued on LIC 809-C. Report continued from LIC9099.... COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 05/14/2024. At 1:22 p.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Laundry units are located in one of the hallways. Night lights were present in the hallways and passages. The last emergency disaster drill took place on 09/20/2024 and are conducted quarterly, with their next one scheduled for Monday, December 30th. Activities were observed in the common areas. OUTDOOR SPACE/ GARAGE: At 1:28 p.m., the LPA observed the back patio which has a covered outdoor area for resident use including a table and chairs. There is a self latching gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. LPA observed an adequate amount of emergency food and water. Garage is used as an office and is maintained locked at all times. RECORD REVIEW: Starting at 1:32 p.m., the LPA reviewed resident records for five (5) out of five (5) residents. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All files were in order. The LPA conducted a personnel file review for (3) staff regularly scheduled and reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files in order. MEDICATION AUDIT: A medication audit for five (5) residents was conducted at 2:29 p.m. and the following was observed. Medications are centrally stored and locked in a locked drawer in the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time. INTERVIEWS: Two (2) staff interviews were conducted. Interviews revealed that staff are knowledgeable in resident rights, forms of abuse, and reporting procedures. Two (2) resident and visiting family member interviews were conducted during the inspection. No concerns noted at the time of the visit. No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report reviewed and provided.the state’s words, verbatim · CDSS document, Dec 27, 2024

Allegation investigated: Facility retained resident with a prohibited health condition.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 3:09 p.m., the LPA met with the Licensee and explained the reason for the visit. During the initial visit on 1/30/2024, between 9:25 a.m. and 10:45 a.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted an interview with the Licensee. On 02/22/2024, the LPA conducted an interview with Resident #1 (R1’s) Home Health. On 2/23/2024, the LPA conducted a file review of Resident #1 (R1’s) documents such as but not limited to, admission agreement, and medical records. On 03/13/2024, the LPA conducted a subsequent visit between 2:45 p.m. and 3:25 p.m. and conducted an interview with R1 and received copies of pertinent documents. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Facility retained resident with a prohibited health condition. On 01/29/2024, the Department received a complaint alleging that the Licensee admitted Resident #1 (R1) to the facility with an unstageable wound/ ulcer. R1 was admitted to Sweet Home Senior Living Facility on 01/26/2024. Prior to living at the facility, R1 was admitted to Country Villa Sheraton Nursing Center, a Skilled Nursing Facility (SNF) from 12/28/2023 to 01/26/2024. R1 was admitted to the SNF for rehab, and received physical therapy, occupational therapy, wound care and medical management. R1 discharged themselves from the SNF against medical advice and was admitted to Sweet Home Senior Living Facility with the plan of having home health. During R1’s stay at the SNF, R1 developed a pressure ulcer on their sacrum. Interview conducted with the Licensee stated that the Licensee received a referral for R1 through a placement agency and the Licensee went to go visit R1 at the SNF to get more information regarding R1’s level of care on 01/25/2024. The Licensee said that the SNF nurse stated that R1 had a wound stage 3 or 4 but did not provide any documentation or paperwork to support the claim. The Licensee stated that R1 would be getting home health through Kaiser Permanente and wound care would be provided for R1. The Licensee believed at the time of R1’s admission to the facility that R1 had a stage 2 wound. Per record review, R1’s ulcer is located on R1’s sacrum and is listed as unspecified in R1’s Kaiser Progress Notes (dated 01/19/2024) and Skilled Nursing Facility Discharge Summary (dated 01/24/2024). R1’s sacrum ulcer was noted as unstageable only in one document, Progress Notes dated 01/22/2024 from Kaiser. R1’s Progress Notes were not provided to the Licensee prior to admission. The documents that the Licensee obtained from the SNF include R1’s Admission Record, Interdisciplinary Discharge Summary and Kaiser Permanente Skilled Nursing Facility Discharge Instructions. None of the listed documents noted R1’s ulcer as unstageable. Although it was alleged that the Licensee was verbally told about R1’s unstageable ulcer, the SNF or Kaiser did not provide documentation to the Licensee that documented R1’s ulcer as unstageable nor did the Licensee obtained Kaiser documents. Additionally, the LPA conducted an interview with R1’s Home Health on 2/22/2024. Interview revealed that R1’s wound improved and had no concerns regarding R1 care at the facility. Home health records did not list the stage of the ulcer. Continued on LIC 9099-C. The LPA did not have sufficient documentation to support the allegation. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. The LPA had several conversations with the Licensee regarding pressure injuries, healing wounds, and Restricted Health Conditions. The LPA educated the Licensee on the importance of not accepting residents with Stage 3, Stage 4 pressure injuries and unstageable wounds/ injuries unless with a hospice waiver and with resident receiving care for the pressure injury from a physician or an appropriately skilled professional. The LPA reminded the Licensee that she should be obtaining pertinent documents for all residents including hospital records. The LPA told the Licensee if a hospital or SNF verbally state that a resident has any kind of wounds or ulcers, that the Licensee needs to follow up appropriately and ensure that the resident is appropriate for the assisted living. The LPA also emphasized the importance of the Licensee obtaining home health and hospice plan of care and wound assessment documents to keep in resident’s file. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 29-AS-20240129144129

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 01/27/2024. At 10:00 a.m., the LPA met with the Coordinating Manager. At 10:20 a.m., the Licensee arrived at the facility. RECORD REVIEW: Starting at 10:30 a.m., the LPA reviewed resident records for five (5) out of five (5) residents. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All files were in order. The LPA conducted a personnel file review for all staff regularly scheduled and reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Personnel files reviewed were observed to be in compliance. At 2:09 p.m., the LPA conducted a review of medication and medication documentation with the Licensee for five (5) residents. No errors observed during the review. At 2:26 p.m., the LPA conducted a brief physical plant tour to ensure there are no health and safety hazards. No deficiencies cited at this time. Exit interview conducted. A copy of the report of provided.the state’s words, verbatim · CDSS document, Jul 11, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:15 a.m., the LPA met with staff and explained the reason for the visit. At 9:40 a.m., the Licensee arrived at the facility. At 9:45 a.m., the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:47 a.m., hot water measured at 107.1-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen drawer. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and three (3) bathrooms for resident's use. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 9:49 a.m., hot water measured between 104.8 and 109.8-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout bathrooms and facility to promote handwashing. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 05/01/2023. At 10:19 a.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Laundry units are located in one of the hallways. Night lights were present in the hallways and passages. Continued on LIC 809-C. OUTDOOR SPACE: At 9:54 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. Between 10:11 a.m. and 10:18 a.m., the LPA conducted interviews with one (1) staff and four (4) residents. The Administrator’s certificate is active and expires on 03/16/2025 Due to time constraints the LPA will return to complete the annual at a later date. No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 27, 2024

Allegation investigated: Resident sustained an unexplained injury while in care. Resident developed a rash while in care.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 9:45 a.m., the LPA met with staff and explained the reason for the visit. At 10:15 a.m., the Licensee and Coordinating Manager arrived at the facility. During the initial visit conducted on 12/02/2021 between 11:20 a.m. and 1:15 p.m., LPA Angel Ascencio conducted an interview with staff, conducted physical plant tour and obtained copies of pertinent documents. On 12/21/2023, at 1:50 p.m., LPA Peraldi conducted a telephonic interview with the Licensee. On 12/21/2023, at 3:10 p.m., LPA Peraldi attempted to conduct a telephonic interview with Resident #1’s (R1’s) case manager. Additionally, on 07/14/2023 and 12/21/2023, LPA Peraldi reviewed R1’s records. Continued on LIC 9099-C. Unsubstantiated Regarding the allegations: Resident sustained an unexplained injury while in care and Resident developed a rash while in care. On 12/01/2023, the Department received a complaint alleging that Resident #1 (R1) had developed skin damage and right ankle rashes while at the facility and “was unable to provide meaningful history.” Per record review, R1 was admitted to the facility on 09/01/2021 and was on home health services. Interview with the Licensee revealed that R1 was on home health services for wound care. The Licensee stated that prior to R1’s death, that R1 changed from home health services to hospice services. Per record review, R1’s home health services included wound care for R1’s buttocks and coccyx area and stage 2 on right ankle. Based on record review, it’s unclear when R1’s rashes developed and if R1 had any injuries while in care at the facility. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2023 · control 29-AS-20211201154331

Allegation investigated: Questionable death. Resident not accorded dignity in relationship with staff.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 9:45 a.m., the LPA met with staff and explained the reason for the visit. At 10:15 a.m., the Licensee and Coordinating Manager arrived at the facility. During the initial visit conducted on 12/07/2021 between 12:00 p.m. and 3:45 p.m., LPA Peraldi conducted an interview with the Licensee, conducted physical plant tour and obtained copies of pertinent documents. On 12/06/2021, a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) however, the referral was not accepted. On 12/10/2021, at 1:50 p.m., LPA Peraldi conducted a telephonic interview Resident #1 (R1’s) Power of Attorney (POA). On 12/06/2021, 12/10/2021 and 03/03/2022, the LPA conducted a telephonic interviews with the complainant. Additionally, on 12/10/2021 and 03/28/2022 the LPA reviewed R1’s records. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: Questionable death. On 12/06/2021, the Department received a complaint alleging that the facility caused the death of Resident #1 (R1) by overdosing R1 with morphine. Per record review, R1 was admitted to the facility on 09/28/2021 and received hospice services up until R1’s death on 12/01/2021. Per record review, R1’s Doctor’s Worksheet for Certificate of Death listed R1’s cause of death A) Cardiorespiratory arrest B) Dementia lewy body C) Atherosclerosis heart disease D) HTN. Record review of R1’s Pathology report dated 03/21/2022 did not include any abnormalities that could be a raise for concern. Interview with R1’s POA on 12/10/2021 did not raise any concerns regarding the care of R1. R1’s POA stated that R1’s POA was at the facility every day prior to R1’s death and had no issues with the intake of R1’s morphine. R1’s POA stated that R1’s POA communicated with R1’s doctors and hospice agency regarding R1’s medication and R1’s POA was in charge of R1’s medical care. Interview with the Licensee revealed that R1’s POA was very involved in R1’s care and medical care. The Licensee stated that the amount of morphine was given to R1 as instructed by R1’s doctor. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Resident not accorded dignity in relationship with staff. On 12/06/2021, the Department received a complaint alleging that the facility staff were "mean" to Resident #1 (R1). Interview with R1’s POA on 12/10/2021 did not raise any concerns regarding the treatment of R1. R1’s POA stated that the facility staff were “wonderful and the care was phenomenal.” Interview with the Licensee did not reveal any issues between staff and R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2023 · control 29-AS-20211206110628