Valley Paradise Boarding Care

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted a case management - deficiencies visit at the facility. LPA arrived to the facility at 10:32 AM. LPA met with the facility staff who contacted the Administrator Naira Nikoyan. The Administrator arrived to the facility shortly after. Entrance interview conducted and the reason for the visit was explained. During today’s visit LPA conducted a physical plant tour, conducted a file review for five (5) residents, collected copies of pertinent documents, and interviewed the Administrator and four (4) residents between approximately 10:35 AM During the physical plant tour LPA observed three (3) resident beds to have full length bed rails installed. LPA interviewed the Administrator who confirmed that no current residents in the facility were receiving care from a hospice provider. LPA informed the Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Administrator expressed understanding and agreed to either remove the full length bed rails from the identified resident’s beds or to submit an exception request to the department to retain the full bed rails. During the physical plant tour LPA observed multiple unsecured prescription and non-prescription medication bottles in resident bedrooms. LPA reviewed resident files and observed three (3) resident’s physician reports which indicated that the residents were not able to store their own medications. LPA informed that Administrator that due to physical arrangements in the facility and the condition or the habits of other persons in the facility medications shall be centrally stored. The Administrator expressed understanding and agreed to properly store all prescription and non-prescription medications at the facility. CONTINUED ON LIC 809C. During record review LPA observed one (1) resident file to be missing a completed medical assessment and proof of a negative TB test. LPA informed the Administrator that the facility shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. The Administrator stated that the facility does have a medical assessment for the resident but that the document was removed by the resident’s responsible party to be updated. The Administrator agreed to submit proof of the completed medical assessment to the department. The following deficiencies were cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a) · Plan of correction due date: Oct 6, 2026

87608 Postural Supports (a)...Postural supports may be used under the following conditions. (5) ... (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care... This requirement is not met as evidenced by: Based on observation and record review the Licensee did not comply with the section cited above as three residents who were not receiving hospice care had full length bed rails installed on their bed which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 22, 2026

Plan of correction: The Administrator agreed to either remove the full length bed rails from the identified resident’s beds or to submit an exception request to the department to retain the full bed rails to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(1)(C) · Plan of correction due date: Oct 6, 2026

87465 Incidental Medical and Dental... (h) The following...shall apply... (1) Medications shall be centrally stored... (C)...due to physical arrangements in the facility and the condition or the habits of other persons in the facility... This requirement is not met as evidenced by: Based on observation and record review the Licensee did not comply with the section cited above as multiple prescription and non-prescription medications were left unsecured at the facility which poses a potential health to clients in care.the state’s words, verbatim · CDSS document, Sep 22, 2026

Plan of correction: The Administrator agreed to properly store all prescription and non-prescription medications at the facility and to submit proof of appropriate storage to CCLD no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Oct 6, 2026

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment...to be kept in the resident's record. This requirement is not met as evidenced by: Based on record review the Licensee did not comply with the section cited above as one resident file was missing proof of a completed medical assessment which poses a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Sep 22, 2026

Plan of correction: The Administrator agreed to submit proof of the completed medical assessment to CCLD no later than POC due date.

Allegation investigated: Staff do not ensure resident receives their mail Staff did not ensure resident participated in the planning of their care Staff are not adhering to admission agreement Staff do not ensure resident is provided copies of records

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 12:05PM and met with the Licensee Naira Nikoyan. Entrance interview conducted. On 05/20/2026, the LPA conducted an initial visit. Between 10:17PM and 1:56PM the LPA conducted a physical plant tour, interviewed two (2) residents and the Licensee, attempted two (2) resident interviews, and reviewed and obtained pertinent documents. During today’s visit at 12:10PM, the LPA and Licensee conducted a physical plant tour, and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff did not ensure resident participated in the planning of their care” It was reported that the Licensee overstepped their role during R1’s doctor’s appointment. Interview with R1 revealed that after their hospice agency unexpectedly discharged them, the Licensee advised residents to obtain updated assessments and medication orders from their physicians. R1 stated the Licensee assisted with transportation and accompanied them to the appointment. R1 alleged that the Licensee asked the doctor whether R1 had dementia, which the doctor denied. The Licensee denied overstepping and stated they initially scheduled the appointment without R1’s consent but apologized and offered to cancel it; R1 chose to proceed. The Licensee stated they accompanied R1 to explain the hospice discharge and answer questions. After introductions and providing needed information, the Licensee reported that they left the room to allow R1 privacy with the physician. The Licensee acknowledged that R1 does not have dementia and is alert and oriented. Interview with Resident #2 (R2) revealed no concerns. R2 stated the Licensee maintains appropriate communication regarding their care and denied any incident of overstepping. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not adhering to admission agreement” It was reported that the facility did not follow the admission agreement by requesting R1 to change the payee’s name on their monthly checks. R1 stated they provide checks payable to the facility on the 1st each month. R1 observed that their April check was not cashed until April 28th and expressed frustration that the funds remained in their account for an extended period. Report Continued on LIC 9099-C The Licensee reported resident payment methods vary by preference, and R1 preferred to write checks and provide them on the 1st. The Licensee stated their bank is far from the facility and they planned to deposit R1’s check on a day when travel would be convenient. R1 then requested the Licensee deposit the check as soon as possible. The Licensee stated they suggested R1 rewrite the check addressed to the Licensee personally so it could be deposited online, which would be immediate, but ultimately deposited the original check at the bank on April 28th. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not ensure resident is provided copies of records” It was reported that the Licensee requested residents to sign documents without providing copies. Interviews did not reveal any concerns. R1 had facility-related documents at their bedside and stated they received copies of all applicable paperwork. R2 stated they do not wish to keep copies but were confident the Licensee would provide them upon request. A resident’s Power of Attorney (POA) also stated they did not want copies but confirmed the Licensee offered them and had no issues obtaining documents when needed. Based on interviews, although the allegation may have happened or is valid, there is insufficient 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, Jul 28, 2026 · control 29-AS-20260513131334

Allegation investigated: Staff are not providing a comfortable environment for resident Staff do not ensure resident has privacy

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced initial complaint visit for the above allegations. The LPA arrived at 3:56PM and met with Licensee Naira Nikoyan. Entrance interview conducted. Between 4:05PM and 5:10PM, the LPA conducted a physical plant tour and interviewed one (1) resident and the Licensee. The following was then determined: Allegations: “Staff are not providing a comfortable environment for resident” and “Staff do not ensure resident has privacy” Report Continued on LIC 9099-C Unfounded It was reported that a facility staff provided Resident #1 (R1) with showers and did not ensure a comfortable environment or maintain their privacy. Interview with R1 revealed that the alleged staff – Individual #1 (I1) was an independent provider, who was previously contracted by R1’s Hospice agency. I1 continued to provide grooming and shower services to R1 independently after Hospice discharge, with R1 paying them directly. R1 did not reveal any immediate concerns and confirmed that I1 was not associated with the facility. R1 did not provide additional information and stated that if they had concerns, they would address it directly with that individual. Record review of the facility’s staff roster and sign in/out sheet confirmed I1 was not employed by the facility. Based on the information obtained, the allegations are deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 29-AS-20260612093556

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required Annual visit at 9:38AM. The LPA met with the Licensee Naira Nikoyan and explained the reason for the visit. Entrance interview conducted. Beginning at 9:59AM, the LPA and the 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 following was observed: COMMON AREAS: At the time of the visit, two (2) living room and dining room furniture were observed to be in good condition. The entryway had cabinets that contained facility supplies and extra linens. There was a fireplace in the second living room, which was observed to be screened. The second living room also had an office area with a locked cabinet that contained files and additional medications. The facility maintained a comfortable temperature throughout the visit. Required postings were observed near the in the first living room and nightlights were maintained throughout the hallways. Report Continued on LIC 809-C KITCHEN: Knives and medications were stored inaccessible in a locked cabinet in addition to a secured medication fridge. Kitchen appliances were clean and in operable condition. The facility had a sufficient supply of perishable and non-perishable food, with an additional pantry in the hallway that contained emergency food and water. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. There was a closet with laundry machines that were operational and contained extra facility supplies. BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each shared. Bedrooms #1 and #3 had a direct exit to the outside with Bedroom #1 approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There were three (3) total bathrooms in the facility: one (1) private restroom, one (1) shared resident restroom, and one (1) visitor restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. The private resident restroom had a locked cabinet that contained facility cleaning supplies. All restrooms were sufficiently stocked with soap and paper products. Hot water was tested and measured between 109.4 degrees F and 109.9 degrees F. OUTDOOR AREA: The outdoor area was shared with the rear Additional Dwelling Unit (ADU) that was occupied by the Licensee. There was sufficient outdoor furniture with shade. The LPA observed two (2) sheds that had general storage and remained locked. No bodies of water noted, and exits were free of obstructions. The side passageways led to the front yard that had two (2) remote and manual operated driveway gates and a door for everyday use. RECORDS: Record review began at 10:20AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident #1 (R1) did not have a Physician’s Report or TB test completed, and consent forms were not signed. The Licensee stated R1 was having issues with their insurance and did not have a Physician. Resident #2 (R2) did not have a TB test result and consent forms were not signed. Resident #3 (R3) had unsigned consent forms and personal rights. Report Continued on LIC 808-C Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The Licensee did not have a health screening or TB test on file and stated they have an appointment to renew the documents. 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 08/13/2025. Smoke and carbon monoxide detectors were tested at 11:32AM and were operational at the time of the visit. One (1) fire extinguisher was observed in the kitchen and was purchased on 07/17/2025 and fully charged. MEDICATIONS: Medication review began at 11:34AM. Medications were centrally stored and kept inaccessible in the kitchen and office cabinet. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. The Licensee did not maintain a current record for Resident #4 (R4) and requested the Hospice Agency to send the record, which did not include medication start dates. Medications for Resident #5 (R5) did not have accurate start dates. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). A Civil Penalty in the amount of $250 was assessed for a repeat violation. The Licensee was informed that continued violation and failure to correct the violation could result in additional civil penalties. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 2, 2025

Allegation investigated: Staff neglect resulted in a resident to be hospitalized

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced complaint visit for the above allegation. LPA arrived at 11:17AM and met with the Licensee Naira Nikoyan and explained the reason for the visit. Entrance interview conducted. At 11:26AM, the LPA and Licensee toured the physical plant areas to ensure there were no health and safety hazards, and the facility was in compliance with Title 22 Regulations. No immediate concerns were observed. Between 11:33AM and 11:50AM, the LPA interviewed two (2) residents. Between 11:53AM and 2:00PM, the LPA interviewed the Licensee, one (1) staff, conducted a medication audit, and reviewed and obtained pertinent documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff neglect resulted in a resident to be hospitalized” It was reported that Resident #1 (R1) was admitted to the hospital in regard to their blood pressure and it was alleged R1 received more than their usual dosage of blood pressure medication. R1 was admitted to the hospital on 07/13/2025 and was presented with generalized weakness, treated for hypovolemic shock, SVT aberrancy, elevated troponin due to NSTEMI Type 1 and 2, and acute renal failure. On the morning of 07/13/2025, R1 was administered six (6) medications, as R1 received everyday: Furosemide 40MG, Gabapentin 300MG, Multivitamin, Glipizide 5MG, Losartan Potassium 25MG, and Levofloxacin 500MG. In the late afternoon, R1 complained of hand numbness and the Licensee evaluated R1, notified hospice, and continued to monitor R1’s blood pressure. Staff #1 (S1) stated that R1’s Systolic blood pressure (SBP) and Diastolic blood pressure (DBP) was monitored every five minutes during which, R1’s reading continued to fluctuate as low as 90 and as high as 133. When R1’s SBP reached 170 and DBP 110, the Licensee administered Hydralazine 25MG, which was prescribed as a PRN (as needed) and instructed one tablet by mouth every 12 hours as needed for SBP greater than 160 and DBP greater than 100. R1 reported receiving a total of six (6) medications in the afternoon and could not recall what medications were administered. Resident #2 (R2) stated they did not observe R1 receive any medication during this time. After the Hydralazine was given, the Licensee and S1 continued to monitor R1’s blood pressure when it was observed to drop significantly and Hospice advised the Licensee to give R1 a glass of water with salt. R1’s blood pressure rose back up in the higher range and the Licensee proceeded to notify hospice that they would call emergency services. Paramedics arrived, evaluated R1, and advised R1 to go to the hospital and R1 refused to go to the hospital. Report Continued on LIC 9099-C R2 reported R1 was very difficult with their care needs and commonly refused services provided by the facility staff, physical therapists, and hospice nurses. Hospital nurses were on the phone with R1 via the paramedics, and R2 convinced R1 to go to the hospital. R2 stated that throughout the incident, hospice nurses were on the phone with the Licensee, and they did everything they could to address R1’s health issues. At the end of the day, the Licensee called emergency services to further assist R1. 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 today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 29-AS-20250721202510

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a post-licensing continuation visit at 9:40AM. The LPA met with the Licensee Naira Nikoyan and explained the reason for the visit. Entrance interview conducted. At 10:10AM, the LPA and the Licensee briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At this time, no immediate health and safety hazards were observed. During the initial visit on 07/11/2025, the LPA observed the following: PHYSICAL PLANT: In the food pantry located in the hallway, the LPA observed expired non-perishable foods dated from 10/27/2022 to 05/28/2025. The Licensee was unaware of the expired food and stated they would update the pantry. Resident #1 (R1) resided in the second living room and was observed to have oxygen administered. Residents in Bedroom #3 also had oxygen stored in their room for use as needed. The LPA did not observe signage stating oxygen was in use for these areas, but did observe one signage for Bedroom #1. The Licensee stated that R1 was not receiving oxygen, and the LPA pointed out the operating oxygen machine attached to the foot of R1’s hospital bed. The Licensee stated Resident #2 (R2) and Resident #3 (R3) were not currently receiving oxygen but utilize it sometimes. Report Continued on LIC 809-C The LPA informed the Licensee that signage of “oxygen in use” need to be posted for safety reasons. In Bedroom #1’s private restroom, the LPA did not observe grab bars along the toilet nor the shower. Additionally, the sink in the restroom was clogged and slow to drain. The Licensee stated that the Hospice nurses utilized the sink to discard water used for the residents’ showers and advised them not to do so. MEDICATIONS: Medications were reviewed for R2 and R3. For R2, three (3) PRN (as needed) medications were observed (Senna-Time 8.6MG, Melatonin 5 MG, and Hydrocodone-Acetamin 5-325MG) and did not have PRN Authorization Letter on file. Several of R2’s prescribed medications were not recorded on a Centrally Stored Medication and Destruction Record (CSMDR) which included Potassium CL ER 10 MEQ filled on 07/02/2025, One Daily Vitamin, Metformin HCL 500MG, Fenofibrate 54MG, and Atorvastatin 10MG each filled on 07/06/2025. Metformin HCL 500MG prescribed on 06/09/2025 was instructed for R2 to take 4 tablets daily, and one dose of 4 tablets remained. R2’s Furosemide 40MG, filled and started on 07/02/2025, was prescribed at 1 tablet twice daily but had not been administered. Cranberry 450MG also filled and started on 07/02/2025 had 6 tablets prepped by Staff and 8 tablets were administered; however, 10 total tablets should have been administered, indicating a discrepancy. R3 had three (3) PRN medications (Hydralazine 25MG, Hydrocodone-Acetamin 5-325MG, and Lorazepam 0.5MG) but did not have a PRN Authorization Letter, nor were any administration logs recorded. Medications filled on 07/06/2025 including Losartan Potassium 25Mg, Glipizide 5MG, and Gabapentin 300MG were scheduled to begin 07/01/2025, were not administered. Melatonin 10MG, filled and started on 07/08/2025, had also not been administered as prescribed. R3’s Nortriptyline HCL 25MG, filled on 07/06/2025 and started 07/01/2025 had 7 tablets prepared by Staff and only 5 tablets taken by R3. Both trazodone 100MG and Atorvastatin 40MG had 7 tablets prepared by Staff, and the remaining tablet counts did not align with the expected usage. Glipizide 5MG filled and started on 06/07/2025 was prescribed at 1 tablet twice daily; it was observed that 19 tablets had been taken from the Morning pack and 10 tablets taken from the Evening pack. The total usage and prescription instructions suggested the medication should have been completed. Report Continued on LIC 809-C Gabapentin 300MG, also filled on 06/07/2025 and taken three times daily, was noted to have 7 capsules left in the Morning pack, 8 in the Evening pack, and the Bedtime pack was unaccounted for. R3’s Furosemide 20MG, filled and started on 06/23/2025, was prescribed for daily intake unless blood pressure dropped below 110 or heart rate below 60. 8 tablets remained, and there was no documentation indicating the medication had been held. Two (2) packs of Jardiane 25MG were observed for R3, both prescribed for daily use. The first pack contained 25 tablets, while the second contained 9 tablets. These packs were filled two (2) days apart, with labels observed to be altered. The Jardiane 25MG was not properly recorded on the CSMDR. The Licensee stated that the residents did not need to take certain medications because they were already taking medications that addressed those same issues. The Licensee did not follow the medication prescription labels and stated that the residents did not want to take the medications, and the Licensee stopped offering them. The Licensee did not order the residents’ medications, but the Hospice Agency was responsible for it, and the Licensee was following the Hospice Nurses’ instructions. The LPA informed the Licensee that they need to follow the Physician’s orders and administer medications according to the medication labels. If the Licensee observed a change in the resident, the Licensee would need to contact the prescribing Physician to make adjustments. The LPA also informed the Licensee that there needs to be documentation of resident refusals, and the Licensee would need to continue offering the medications and inform the prescribing Physician. Additionally, PRN medications need to be documented each time they are administered which include the reason for the administration, date, and time. The CSMDR also showed inconsistencies pertaining to the date filled and date started of each medication. The LPA also discussed with the Licensee reporting requirements, as R3 was observed to be admitted to the hospital. Report Continued on LIC 809-C RECORDS: Record review of resident files revealed that R2, R3, and Resident #4 (R4) did not have completed documents such as Admission Agreements, Appraisals, Personal Rights, and Consent Forms. R2 and R3 had Physician’s Reports, however, R4 did not have their Physician’s Report or TB test results. R1 was admitted to the facility on 07/09/2025 and the Licensee did not complete any required documents upon admission to the facility. The Licensee stated they were waiting for R1’s family and Hospice to provide the documents. The LPA informed the Licensee that the required documents should be completed prior to being admitted to the facility. The Licensee stated they would work on obtaining and completing the required documents for all residents. The LPA was not able to complete a review of Personnel records because the Licensee did not have any documentation completed for two (2) Staff in addition to both Staff not being fingerprint cleared. Staff #1 (S1) had been employed since 02/25/2025 and assisted residents as well as maintained facility files. Staff #2 (S2) had been employed since 07/02/2025 and had since been the primary caregiver in addition to the Licensee. S1 and S2 did not obtain their First Aid/CPR training or receive their 40 hours of initial training. S1 and S2 need to complete their Personnel Records, Health Screening with TB test results, First Aid/CPR Training, Criminal Record Statement and Clearance, and 40 hours of initial training. The facility has not conducted any emergency drills or maintained their Infection Control Plan and Emergency Disaster Plan. The LPA requested the documents and the Licensee and S1 were unable to provide them. Additionally, files were not readily available nor kept and maintained in a centrally stored location on the facility’s premises. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies are cited (Refer to LIC 809-D). Exit interview conducted. A copy of today’s report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a post-licensing visit at 10:04AM. The LPA met with the Licensee Naira Nikoyan and explained the reason for the visit. Entrance interview conducted. Beginning at 10:12AM, the LPA and the 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 following was observed: COMMON AREAS: At the time of the visit, two (2) living rooms were observed with furniture in good condition. The facility’s entryway had an extra supply of linens and supplies. Required postings were observed in the first living room. LPA observed an unoccupied bed in the first living room and the Licensee understood it needed to be removed. The second living room had an office area with a locked cabinet that stored extra medications. LPA observed Resident #1 (R1) residing in the second living room who was also observed at 12:03PM to be Bedridden. The Licensee stated R1 was admitted two (2) days ago and Hospice had placed them there. The LPA notified the Licensee that R1 will need to be relocated to the approved Bedridden bedroom by the end of today, 07/11/2025. Emergency food and water were stored in a hallway pantry. The facility maintained a comfortable temperature throughout the visit. Smoke and carbon monoxide detectors were tested at 10:52AM and were operational at the time of the visit. Report Continued on LIC 809-C KITCHEN: Knives and Medications were stored inaccessible in a locked cabinet. However, LPA observed accessible steak knives in a cabinet across from the refrigerator. Additionally, the Medication fridge near the same cabinet was not secured. Kitchen appliances were clean and in operable condition. The facility had a sufficient supply of perishable and non-perishable food. LPA observed operating laundry machines in a kitchen closet that also stored extra facility supplies. BEDROOMS/RESTROOMS: There were three (3) total bedrooms with dual occupancy. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom #1 was approved for one (1) Bedridden resident and had a direct exit to the outside. Bedroom #3 had a direct exit to the outside and LPA observed Resident #2 (R2) had access to their Insulin Pen Needles and had a needle disposal bin on their bedside. After reviewing Physician’s Reports, R2 and Resident #3 (R3) residing in Bedroom #3 were not allowed access to store their own medications and pose a safety risk. The Licensee stated that R2 did not want assistance with their Insulin, and the Licensee allowed R2 to have possession of it. There were three (3) total restrooms in the facility: one (1) private restroom attached to Bedroom #1, one (1) guest restroom in the hallway, and one (1) shared resident restroom in the hallway. The restrooms were clean and sanitary. Hot water was tested and measured between 118 degrees F and 118.9 degrees F, which is within the required range. OUTDOOR AREA: The outdoor area consisted of the front yard and rear patio. The LPA observed two (2) aerosol bug repellent sprays on the patio furniture. The front yard had two (2) driveway gates that were remote and manually operated, with an additional gate entrance for everyday use. LPA observed an accessible Additional Dwelling Unit (ADU) in the rear which was occupied by the Licensee and their family. The side of the ADU had two (2) sheds: one (1) contained various tools and was unlocked, and one (1) shed contained general storage that was locked. No bodies of water noted, and exits are free of obstructions. Report Continued on LIC 809-C MEDICATIONS: Medication review began at 10:57AM. Medications were centrally stored and kept inaccessible in the kitchen and office area. Medications were observed for two (2) residents. No immediate concerns were observed. RECORDS: Record review began at 12:13PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Residents’ documentations were not complete at this time. LPA was unable to review Personnel records due to the facility not completing them upon the Staff’s employment. Additionally, two (2) Staff did not obtain their fingerprint clearance per regulation. One (1) Staff requested clearance but was not cleared due to an incomplete application. Due to time constraints, the LPA will return at a later date to conduct a continuation visit. Pursuant to Title 22 of the CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited. (Refer to LIC 809-D). An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee understands that continued violation of the facility’s fire clearance may result in additional civil penalties. An immediate civil penalty of $100 per day for a maximum of 5 days in the amount of $1,000 for employment without a criminal record clearance and/or exemption was issued for two (2) Staff (Refer to LIC 421BG). The Licensee understands that continued employment without a criminal record clearance and/or exemption may result in additional civil penalties. Exit interview conducted. A copy of the Appeal Rights and today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 11, 2025

Type of visit: Prelicensing

(PAGE 1) Licensing Program Analyst (LPA) Mosley conducted a pre-licensing visit to the above noted facility at 10:00 a.m..The LPA met with applicant, Naira Nikoyan. This is a new facility with a Hospice Waiver for six (6). The facility is single story house. At 10:00 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) non-ambulatory residents in rooms 1,2, and 3 and 1 bedridden resident in room 1. The facility bedrooms are all shared room(s), double occupancy. Room # 1 and Room #3 have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. The beds are furnished with box springs, comfortable mattress, and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. There are 3 bathrooms. 1 bathroom is designated as a staff bathroom. The resident bathroom(s) has a shower with non-skid materials. The toilet and shower have grab bars. Bedroom #1 has a private bathroom. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F. Report Continued from LIC 809C PAGE 2... (PAGE 2) (Report Continued from LIC 809 PAGE 1) Resident and staff records are stored in filing cabinet which is currently located in the living room area. Medications are centrally stored in a locked cabinet in the kitchen area and also have a locked mini refrigerator for medications that require refrigeration. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a cabinet at the entrance of the facility. Kitchen knives are stored in a locked cabinet in the kitchen where the medications are stored. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the laundry area. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a non-functional fireplace in the living room. It is screened and there are no tools. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. Report Continued from LIC 809C PAGE 3.... (PAGE 3) (Report Continued from LIC 809 PAGE 2..) The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is a fire extinguisher located in the kitchen area that was fully charged and do not exceed the expiration date. Hot water was tested in each bathroom, which included the resident bathroom(s) and any common bathrooms, in addition to the kitchen; and, the hot water ranged from 105 to 120 degrees Fahrenheit. The laundry area is located in the hallway adjacent to the kitchen. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the bathroom locked. Extra incontinence supplies are stored in the laundry area. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at the entry way. The emergency telephone numbers are posted in the entry way. Other required postings are posted at the entry way. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the house with a table and chairs where residents can sit. The entire property is fenced. There is an ADU located in the back of the property where the licensee and family reside. No citations issued on a pre-licensing visit. During today’s visit COMP III orientation was completed with facility Administrator / Licensee Naira Nikoyan. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.the state’s words, verbatim · CDSS document, Nov 22, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: NIKOYAN, NAIRA - Licensee/Administrator Interview Method: Telephone interview On 10/24/2024, 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 that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. 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. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 24, 2024