Valley Village Senior Living

Allegation investigated: Staff are not providing activities for a resident in care

Licensing Program Analyst (LPA) Quoc Huynh conducted an initial complaint visit for the above allegation. The LPA arrived at 10:19AM and met with Administrator Sargis Ayvazyan. Entrance interview conducted. Beginning at 10:27AM, the LPA and Staff toured the physical plant, and no immediate concerns were observed. Between 10:27AM and 11:37AM, the LPA interviewed three (3) residents, one (1) staff, and the Administrator. The following was then determined: Allegation: “Staff are not providing activities for a resident in care” It was reported that the facility was not providing residents with activities or exercise, and that residents only watch television (TV) throughout the day. Report Continued on LIC 9099-C Unsubstantiated During the physical plant tour, the LPA observed a whiteboard near the kitchen that stated “Excercise 11AM & 4PM.” In the entertainment center and cabinet near the whiteboard, the LPA observed a bingo set, jumbling tower (jenga), and dominos. The LPA additionally observed adolescent puzzles, crayons, and a coloring book in Bedroom #3. Throughout the visit, residents were observed resting in bed watching TV, and at approximately 11AM, three (3) residents were brought into the living room to utilize an electric foot massager, as part of the scheduled exercise activity. Interview with staff indicated that the 11AM and 4PM exercise sessions consist of residents using an electric foot massager. Staff reported that they frequently accompany two (2) residents on walks in the neighborhood. Staff stated that the residents’ routine includes walking around the facility and the front yard, watching TV, and playing games. Staff further stated that three (3) residents participate in painting and games in the living room. The Administrator reported that they are often present at the facility and observe staff and residents engaging in activities approximately “ninety-five percent (95%) of the time.” Activities include walking down the street, occasional outings to a nearby Starbucks, puzzles, crosswords, and similar activities. Interview with three (3) residents confirmed that structured activities are not offered at the facility, and they denied participating in the scheduled 11AM and 4PM exercise sessions. Resident #1 (R1) reported that every other day staff took them on a short walk in the neighborhood and that they perform exercises independently in their room. R1 stated that they were content with watching TV and going on walks. Resident #2 (R2) stated that the staff come and go from their room but were unaware of any activities offered. Resident #3 (R3) reported spending their days watching TV, walking around the facility, and going outside to smoke. R3 expressed a desire to go on walks in the neighborhood and outings to the store but stated that staff do not take them. Based on interview and observation, 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, Aug 18, 2026 · control 29-AS-20260810121304

Allegation investigated: Facility did not provide records to resident's responsible party

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 10:19AM and met with Administrator Sargis Ayvazyan. Entrance interview conducted. On 04/30/2026, LPAs Huynh and Angela Barutyan conducted an initial visit. Between 1:48PM and 3:15PM, the LPAs conducted a physical plant tour, interviewed the Administrator, and reviewed and obtained pertinent documents. During today’s visit, LPA Huynh conducted a physical plant tour at 10:27AM, and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Facility did not provide records to resident’s responsible party” It was reported that the facility Administrator did not provide Resident #1’s (R1) Responsible Person (RP) with R1’s records. Interview with the Administrator indicated that the RP requested medical documents on approximately 04/13/2026 when they removed R1’s belongings and was informed that the facility did not maintain medical records. The RP then requested R1’s file again on 04/29/2026 and the Administrator stated they intended to provide the documents. After the allegation was disclosed during the initial visit conducted on 04/30/2026, the Administrator then proceeded to rescind their statement and stated the RP only requested documents on 04/29/2026. Interview with the RP on 08/10/2026 revealed that the Administrator only provided them with R1’s admission agreement, despite requesting the file in its entirety including medication lists. The RP reported that the Administrator informed them that the facility does not “have any here.” During today’s visit, the Administrator confirmed and provided proof that they provided the RP with the Admission Agreement, Urinary Tract Infection (UTI) lab report, and prescribed antibiotic order to treat the UTI on 04/30/2026. The Administrator stated that the RP did not request additional documents and confirmed that the remainder of R1’s file was not provided. Based on interviews, the preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. Allegation: “Staff did not seek medical attention to resident in a timely manner resulting in death of resident” It was reported that Resident #1 (R1) was not provided medical attention in a timely manner, which resulted in their death. R1’s Physician Report dated 07/23/2023 documented diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and generalized weakness. R1 was non-ambulatory, required continuous bed care, assistance with activities of daily living (ADLs), and was noted to receive hospice services due to COPD. Interview with R1’s Responsible Person (RP) indicated that R1 experienced a significant change in condition between 03/01/2026 and 04/06/2026, including a urinary tract infection (UTI), weight loss due to loss of appetite, and wound care needs. The RP reported that when R1 was admitted to home health services in February 2026, R1 was verbal and eating meals without complications. The RP stated that the Administrator did not notify them of R1’s UTI, loss of appetite, and overall decline until the RP visited the facility on 04/06/2026 and observed R1 to be in need of medical attention. The RP reported they did not contact 911 themselves because they trusted the Administrator to oversee R1’s health. The Administrator reported that R1 contracted a UTI in March 2026 and was prescribed antibiotics, which reportedly resolved the issue. The Administrator stated that approximately two (2) weeks prior to R1’s hospitalization and death, they notified the RP that R1’s condition was declining and that R1 was not eating. On 04/08/2026, a caregiver informed the Administrator that R1’s oxygen saturation was low. The Administrator stated they contacted the RP for guidance, and the RP confirmed the need for hospital transport. Report Continued on LIC 9099-C Interview with staff indicated no overall concerns. Staff reported they monitored R1’s vital signs two (2) times a day and noted no issues until 04/08/2026, when R1’s oxygen level and blood pressure were low. Staff stated they notified the Administrator, who arrived at the facility approximately fifteen (15) minutes later, followed by ambulance services approximately five (5) minutes after the Administrator’s arrival. Staff also confirmed R1’s antibiotics for the UTI were administered two (2) times a day for ten (10) days as prescribed. Home health records documented diagnoses including hypertensive heart disease, COPD, hypotension, depression, and aphasia. On 03/16/2026, R1 was noted to have poor appetite and was only consuming approximately fifty percent (50%) of meals. On 03/23/2026, R1 exhibited symptoms suggestive of a UTI, and on 03/30/2026, an open wound on the coccyx area was documented along with urine testing confirming a UTI. On 04/04/2026, R1 completed the prescribed antibiotics, and UTI symptoms were noted as relieved. On 04/05/2026, R1’s appetite was reported as “fair,” and the Stage II pressure ulcer on the sacral area demonstrated signs of healing. Home health records did not reveal additional complaints or abnormalities observed during visits. Hospital records showed that on 04/08/2026, R1 was admitted with unspecified cardiac arrest. Critical interventions were required due to a high probability of imminent organ system deterioration. R1 ultimately succumbed to a cardiac arrest while bradycardic, and intubation efforts were unsuccessful. The Los Angeles County Medical Examiner Report confirmed R1’s cause of death as natural, due to sepsis. A secondary cause of death was documented as a kidney infection resulting from a lower UTI and kidney stones. A Medical Examiner Investigator additionally confirmed that R1’s death did not appear negligent and could not have occurred even if R1 received “top notch” medical care. Based on interviews and record review, 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, Aug 18, 2026 · control 29-AS-20260429152318

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Aug 28, 2026

(a) In addition to the rights listed in Section 87468.1… (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days… This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the above cited section in R1’s Responsible Person was not provided all of R1’s records which poses/posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: The Licensee will provide R1's Responsible Person with R1's entire file and provide proof to CCLD by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:06AM. The LPA met with Staff Marina Vardapetyan. The Licensee Sargis Ayvazyan was contacted via telephone call and was unavailable during the visit. Entrance interview conducted. Beginning at 10:20AM, the LPA and Staff 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: KITCHEN: The LPA observed knives and cleaning supplies stored inaccessible. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Required postings were located on the entryway wall. There was an office desk and file cabinets in the living room. The facility maintained a comfortable temperature throughout the visit. Nightlights were observed throughout the facility. Laundry machines were observed in the hallway in good condition with secured detergent. Report Continued on LIC 809-C BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each shared. Bedroom #1 had a direct exit to the outside and cleared for one (1) bedridden resident. The blinds on the exit door were observed to be in disrepair with several panels missing. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the residents’ rooms. There were two (2) total restrooms in the facility: one (1) private and one (1) common restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap and paper products. Hot water was tested and measured between 113 degrees F and 116.2 degrees F. OUTDOOR AREA: The surrounding grounds had a shaded patio area equipped with furniture in good condition for resident and visitor use. There were two (2) emergency exits: a driveway gate and everyday door. All exits and passageways were free of obstructions. The LPA observed one (1) secured shed. RECORDS: Record review began at 10:34AM. 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 04/16/2026. Smoke and carbon monoxide detectors were tested at 11:18AM and were operational. A fire extinguisher was observed and purchased on 08/21/2025. Emergency water was not observed during the visit. The Licensee and staff stated that the residents utilize the supply as everyday drinking water and ran out. The LPA explained the purpose of having an emergency food and water supply. Report Continued on LIC 809-C MEDICATIONS: Medication review began at 11:21AM. Medications are kept inaccessible in between the dining room and kitchen. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and the centrally stored medications and destruction record. One resident’s Lisinopril 20MG medication was observed to have a missing dose and staff stated they dropped the dose and discarded it. The staff stated that they reported it to the Licensee; however, no record of the destruction was recorded and the Licensee denied receiving notification. The resident was also prescribed Clonidine HCL 0.1MG, Quetiapine Furmarate 25MG, and Quetiapine Furmarate 50MG instructed to be administered in the evening. The LPA inquired about the dosage from 06/30/2026 which remained in the bubble packs and staff were unable to provide an explanation. Review of the resident’s Medication Administration Record documented that the dosages were signed off and administered. Further review of the resident’s remaining evening medications revealed they were properly administered. 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). The report was reviewed with the Licensee via telephone call who designated staff to sign the report. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 7, 2026

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20260429152318). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation. During the visit on 04/30/2026, LPAs observed Staff #1 (S1) and Staff #2 (S2) without a criminal record clearance transfer. Staff and Administrator Sargis Ayvazyan stated that S1 has been working at the facility for a few months and S2 started today on 04/30/2026. Upon record review, LPAs observed that incident and death reports for Resident #1 (R1) were not submitted to the Woodland Hills North Regional Office. The Administrator stated that the incident report of R1’s hospitalization was submitted via email but was unable to provide proof. The Administrator additionally confirmed that R1’s death report was not submitted. LPAs reviewed medications for R1 and observed R1’s centrally stored medication and destruction record (CSMDR) was not up to date. Medications did not have a physician’s order on file. Staff stated that the medications for R1 were destroyed, however, no written documentation could be provided. At 03:40PM, LPAs observed R1’s PRN Senna Tab 8.6mg at the facility. Staff #3 (S3) stated they kept the medication as they were using it for their stomach pain. Administrator destroyed the medication during the visit. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Civil penalties were issued in the amount of $850 for criminal record clearance ($600) and repeat violation ($250) for CCR section 87465(e) cited on 07/02/2025 regarding physician’s orders to be maintained for medications. Failure to correct the deficiencies may result in additional civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: May 1, 2026

Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on record review, observation, and interview, the licensee did not comply as two (2) out of three (3) staff members observed at the facility did not have a transfer of criminal record clearance which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator stated he will associate the two staff members by the due date and submit proof to CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(e) · Plan of correction due date: May 1, 2026

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file... This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited as Resident #1 (R1)'s medications did not have physician's orders on file which posed an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator stated he will obtain the written physician's orders residents medications and will provide proof to CCLD by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h) · Plan of correction due date: May 1, 2026

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply as Resident #1 (R1)'s centrally stored medication and destruction record (CSMDR) was not up to date which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator stated he will audit the CSMDRs for the current residents and will submit a signed statement of understanding of the section cited to CCLD by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(i) · Plan of correction due date: May 1, 2026

(i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record... This requirement is not met as evidenced by: Based on interview, record review, and observation, the licensee did not comply as R1's medications were not properly destroyed nor documented upon their termination of services which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator destroyed R1's medication during the visit. Administrator will submit a signed statement of understanding including staff signatures to CCLD of the section cited by the due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 7, 2026

Reporting Requirements (a) Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply as incident and death reports for Resident #1 (R1) were not submitted to the Department which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator stated he will submit R1's incident and death report to the Department. Administrator will also submit a signed statement of understanding of the section cited to CCLD by the due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 8:55AM. The LPA was greeted by Staff, informed them of the reason for the visit, and Staff proceeded to notify the Licensee. The Licensee Sargis Ayvazyan arrived at 9:58AM. Entrance interview conducted. Beginning at 10:30AM, the LPA and the Licensee 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. The following was observed: KITCHEN: Knives were stored inaccessible in a locked drawer near the dishwasher. Cleaning supplies were located under the sink in a locked cabinet. Kitchen appliances were clean and in operable condition. Food in the refrigerator was observed to be properly stored with labels and dates. Emergency food and water was located in a cabinet above the refrigerator. Hot water was tested and measured at 118.6 degrees F. LPA observed one (1) fire extinguisher that was purchased on 07/11/2024 and a first aid kit mounted on the wall. Report Continued on LIC 809-C COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The living room had an office area which contained locked file cabinets and a mini fridge that contained medications. LPA observed night lights throughout the facility. The facility maintained a comfortable temperature throughout the visit. Grab bars were provided in the hallway for residents’ use as needed. Also located in the hallway was a laundry closet that was observed to be operational. Locked hallway cabinets contained detergent and general cleaning supplies. BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each with dual occupancy. Bedroom #1 had a direct exit to the outside and is cleared for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinets. There were two (2) total restrooms in the facility: one (1) shared common restroom and one (1) private restroom located in Bedroom #3. 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. Both restrooms had locked cabinets under the sink that stored extra towels or cleaning supplies. Hot water was tested and measured between 115.2 degrees F and 119.8 degrees F. OUTDOOR AREA: LPA observed a grill, and one (1) patio area equipped with furniture for residents and visitors to use. There is one (1) front door gate and driveway gate used for emergency exits and it is remote and manually operated. No bodies of water noted, and exits are free of obstructions. LPA observed one (1) shed that contained general storage and outdoor equipment that remained locked. Report Continued on LIC 809-C RECORDS: Record review began at 10:58AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. LPA observed four (4) out of six (6) residents did not have an Appraisal/Needs and Services Plan on file. The Licensee stated the Appraisals are not required due to the verbiage of the documents, to which the LPA and Licensee had a discussion on the regulations and reviewed current forms. One (1) out of six (6) residents did not have a Physician’s Report or TB test. The Licensee stated they will obtain the resident’s Physician Report from their previous nursing facility. The LPA discussed with the Licensee the use of common area cameras and advised that they update residents’ Admission Agreements with an Addendum stating the use and knowledge of cameras. LPA advised the Licensee to update their Plan of Operation as well regarding the use of cameras. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medication review began at 2:37PM. Medications were centrally stored and kept inaccessible in cabinets located near the dining room and hallway. Medications were observed for three (3) residents. Medications are labeled and checked for expiration dates. LPA observed Resident #1 (R1) was prescribed two (2) PRN Medications (Senna 8.6MG and Quetiapine 50MG) and it was not documented when Staff administered them to R1. Additionally, R1’s PRN Authorization Letter authorized the administration of Quetiapine 50MG, but did not list Senna 8.6MG. The Licensee obtained an updated PRN Letter before the conclusion of the visit. The Licensee stated that the facility is in the process of working with their Pharmacy to obtain updated Centrally Stored Destruction and Medication Records (CSDMR) and that four (4) out of six (6) residents did not have a CSDMR. Report Continued on LIC 809-C The review of Resident #2 (R2) revealed that nine (9) out of twelve (12) of their medications were not documented on their CSDMR. Additionally, R2 did not have a PRN Authorization Letter and the Licensee stated they would obtain it. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, the 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 05/14/2025. Smoke and Carbon Monoxide alarms were tested at 3:55PM and were operational. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were 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 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:31AM. LPA met with Caregiver Mkrtich Zorayan and Licensee/Administrator Sargis Ayvazyan who arrived at 09:55AM. Entrance interview conducted. Beginning at 9:33AM, the LPA, along with the Caregiver toured 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 following was observed: Fire extinguisher is fully charged and was last purchased 07/11/2024. Hardwired smoke and carbon monoxide detectors were tested at 09:49AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating. KITCHEN: LPA inspected the kitchen at 9:32AM. Knives are locked in a drawer next to the sink and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food. Food was stored at appropriate temperatures. BEDROOMS: There are 3 (three) total bedrooms in the facility and all are designated as shared rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. BATHROOMS: There are 2 (two) total bathrooms, of which 1 (one) is attached to resident room. Restrooms were observed to contain nonskid mats. At 9:45AM, LPA observed suction grab bars by the showers which were loose and not functioning properly. Water temperatures in both bathrooms were measured between 118.5 and 118.7 degrees Fahrenheit, which is within the required range. LPA observed storage space closets in hallway containing clean linens for resident use. Report Continued on LIC 809-C COMMON AREAS: This includes the living room and dining area in the kitchen. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed surveillance cameras in the common areas. 2 (two) of the surveillance cameras have an auditory component but are muted. OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. At 9:52AM, LPA observed the exit door outside to self-latch but failed to self-close. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 07/01/2024. RECORD REVIEW: LPA began record review at 10:25AM. LPA reviewed 5 (five) out of 5 (five) resident files and 4 (four) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All resident and staff files were complete and had no missing documents. MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the living room. LPA began medication review at 12:02PM and medications for 3 (three) residents were observed. 3 (three) out of 3 (three) resident medications observed were labeled and stored properly. PRN medications for 3 (three) out of 3 (three) residents observed were not properly documented at the time of the visit. 2 (two) medications for Resident #1 (R1) were not documented on the centrally stored medication and destruction record. INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and 2 (two) residents. During today's visit, LPA obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 26, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: . Staff are not ensuring resident receives Personal and Incidental Allowance (P&I) 2. Staff did not ensure resident receives mail

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and was let into the facility by Alisa Arshakyan, Staff. Sargis Ayvazyan, Administrator was contacted by telephone and he arrived at 11:17am to conduct the visit. The reason for today's visit was provided. On today's visit, LPA Yee conducted an interview with the Administrator at 11:29am, Resident #1 at 12:13pm reviewed and obtained copies of Resident #1's file at 12:01pm. Per information received from interviews conducted with the Administrator and Resident #1 on today's visit regarding Allegation #1 - staff are not ensuring resident receives Personal and Incidental allowance(P&I), both state that Resident #1 receives $60.00 dollars every month since August 2023. The facility became the Unsubstantiated the payee for Resident #1's funds in July 2023 but no P & I amount was included until August 2023. Per the Administrator, Resident #1 is a smoker and they purchase 3 cartons of cigarettes for a total of ninety dollars($90.00) and charge Resident #1, eighteen dollars ($18.00) for incontinence products. The balance of sixty dollars($60.00) is given to Resident #1. Resident #1 confirmed that $60.00 was received for January 2024. However, the facility does owe Resident #1 an additional seventeen dollars for January 2024 due to an increase in the P & I amount from $168.00 to $177.00 per month effective 1/1/24. The facility also needs to reimburse the resident $108.00 (6 months x $18) for the incontinent products charged from August 2023-January 2024 as the incontinence products are covered under the basic Social Security Income and State Supplemental Payment rate. The Administrator will provide evidence to Licensing that the resident has been provided with the difference in the P & I rate and the reimbursement for the incontinence charges totaling $125.00 by not later than 1/12/24. Based on the information received on today's visit, there was insufficient evidence to conclude that the facility failed to ensure that Resident #1 received their P & I allowance, therefore, Allegation #1 is UNSUBSTANTIATED. Regarding Allegation #2 - Staff did not ensure that Resident receives mail, per the information received on today's interviews, Resident #1 receives mail but the complaint was generated as a result of a package that was sent to Resident #1 by family, was not received. Per information received, the facility has issues with receiving packages due to the way the facility is situated. The facility is located behind a family home with a separate address of 5539 Vantage Avenue. The facility is located at the end down a long drive way and their packages are delivered in error to the front house and this is not a issue as the facility has access to the front house. In the case of this complaint, Resident #1's package was addressed incorrectly to 5529 Vantage Avenue and is a non-existent address. Resident #1 did not receive the package as a result of the error in the address used by the family and not due to the facility's failure to ensure that the resident receives mail. Therefore, Allegation #2 is UNSUBSTANTIATED. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided. Resident #1 has never been told that they may not leave the facility. Per the Administrator, Resident #1 resident goes out everyday with staff. Staff takes Resident #1 to Starbucks everyday and pays for his drinks and to 711 as needed. Per the Administrator, the resident is supervised by the staff due to concerns with Resident #1 purchasing alcohol and easily getting tired when walking distances and seating on the ground. Staff escorts Resident #1 and uses a wheelchair when resident tires. Per interview with Resident #1, they are told that they may not go out in the community alone due to their diagnosis of dementia which is bogus per Resident #1. Staff prevents Resident #1 from leaving the facility and has chased Resident #1 to the corner when resident leaves the facility without staffs' knowledge. Resident #1 is allowed to leave the facility only when supervised by staff. Resident #1 specifically asked LPA to let the Administrator know that Resident #1 can leave the facility unsupervised. By the actions of the facility, Resident #1 feels that they are not allowed to leave the facility unsupervised. Based on the information received on today's visit, Allegation #3 is SUBSTANTIATED. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.the state’s words, verbatim · CDSS document, Jan 8, 2024 · control 29-AS-20240103145010

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jan 9, 2024

Personal Rights: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. Resident#1 who is determined to be able to leave facility unassisted, is not allowed to leave the facility un-supervised until todaythe state’s words, verbatim · CDSS document, Jan 8, 2024

Plan of correction: Licensee will ensure that the residents are allowed to leave the facility unsupervised if they have been determined by their physician to be able to leave the facility unassisted. Provide a written and signed plan of action that the facility will implemement to ensure that residents are allowed to leave the facility by 1/9/24

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to deficiencies noted during a visit to the facility today. The reason for today's visit was provided. During today's visit LPA Yee received information that the facility receives Resident #1's Social Security Income and State Supplemental Payment in the facility's bank account. A copy of the Surety Bond was requested and could not be provided. A request was made by the facility administrator to the facility's insurance agent to obtain coverage today and will not be available for a couple of days. Evidence that a Surety Bond with the appropriate limits will be provided to Licensing as soon as it becomes available. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted, Appeals Rights discussed and a copy was provided.the state’s words, verbatim · CDSS document, Jan 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87216(a)(1) · Plan of correction due date: Jan 16, 2024

Bonding: Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.(1)The amount of the bond shall be in accordance with the following schedule: Total Safeguarded Per Month Bond Required: $750 or less -$1,000, $751 to $1,500.- $2,000, $1,501 to $2,500 - $3,000 Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. The facility does not have a surety bond for R1's SSI fundsthe state’s words, verbatim · CDSS document, Jan 8, 2024

Plan of correction: Licensee will purchase a Surety Bond in the amounts that will cover all resident funds handled by the facility. Evidence of an active Surety Bond will be provided to the Department by no later than 1/16/24