Victor Royale

Allegation investigated: Staff is over medicating residents Staff does not ensure facility is free of hazardous odors Staff yell at residents Staff are interrupting the sleep of residents Staff threatened residents in care Staff does not ensure facility washing machines are in good repair Staff do not provide adequate meal portions to residents

On 07/14/26, at 7:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Alise Nazarian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 07/14/26, LPA Saucedo asked for the census, staff, and resident rosters. On 07/14/26, at 7:55am, LPA Saucedo conducted a physical tour, interviewed both residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff is over medicating residents. It is alleged that staff are administering medications above the prescribed dosage. During LPA’s physical tour, LPA reviewed five (5) random resident medications that were in bubble packs, and the proper dosage was prescribed and the qualified staff signed for it. In addition, the five (5) random resident medications that were reviewed were prescribed by a pharmacist/doctor. LPA also interviewed five (5) residents that confirmed they do not feel over medicated. Furthermore, the Glendale Police Department visited and interviewed residents on 07/08/26, and they are no complaints about medications. LPA interviewed nine (9) staff that confirmed that residents are not over medicated. Three (3) out of the nine (9) staff interviewed are staff that provide medication to residents, and they also confirmed that the medication is in bubble packs and giving over medication to residents would be difficult and is not allowed. Therefore, based on the interviews conducted and the medications reviewed the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not ensure facility is free of hazardous odors. It is alleged that staff clean with bleach and there is a strong smell in the resident’s rooms. During LPA’s physical tour, LPA did smell and observe various cleaning supplies being used for cleaning in their original container, but no residents were around when the cleaning supplies were being used. Furthermore, the cleaning supplies are locked, stored and inaccessible to residents. LPA interviewed five (5) residents that confirmed that the cleaning and the odor of the room does not bother them. During LPA’s interview with nine (9) staff they confirmed different cleaning supplies are used to clean but residents don’t have access to them. Therefore, based on the interviews conducted and the LPA’s observation the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff yell at residents. It is alleged that staff #1 (S1) yell at residents. During LPA’s physical tour, LPA did not witness S1 and/or any of the other eight (8) staff that were interviewed yelling at residents. LPA also interviewed five (5) residents that confirmed S1 does not yell at them. Furthermore, the nine (9) staff interviewed including S1 confirmed they have never yelled at any of the residents. In addition, the Glendale Police Department visited and interviewed residents on 07/08/26, and did not observe any signs of abuse or neglect. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff are interrupting the sleep of residents. It is alleged that staff #1 (S1) wake up residents at 4:30AM to clean their room. During LPA’s review of the LIC 500, staff #1 comes in at 6AM. LPA also interviewed S1 that confirmed they do not come in before 6AM. In addition, the other eight (8) staff that were interviewed confirmed that S1 does not come in before 6AM. LPA also interviewed five (5) residents that confirmed S1 does not interrupt their sleep and S1 does not start cleaning their rooms until 6:30AM and/or 7:00AM. During LPA’s physical tour at 7:55AM, LPA observed S1 cleaning some rooms and the hallways of the facility without disturbing residents. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff threatened residents in care. It is alleged that the administration has told residents that if they complain, they will be required to sign a letter and be removed from the facility. During LPA’s interview with nine (9) staff they confirmed that no residents have complained about being threatened by the administration and if they complain they will be required to sign a letter and be removed from the facility. One (1) out of the nine (9) staff confirmed that the residents do sign paperwork that is given to them from the office but nothing regarding complaining it’s paperwork like payments received, Appraisals etc. During LPA’s interview with five (5) residents they confirmed that they have not been threatened by the administrator and/or anybody in the facility. In addition, the Glendale Police Department visited and interviewed residents on 07/08/26, and did not observe any signs of abuse or neglect. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff does not ensure facility washing machines are in good repair. It is alleged that the washing machine has not been working for the past two (2) weeks and residents are wearing the same clothing. During LPA’s physical tour of the facility, LPA observed two (2) washers and two (2) dryers. LPA did not observe any dirty laundry in the laundry area. One (1) machine is also available for use by residents who are able and who desire to do their own personal laundry. During LPA’s interview with five (5) residents they confirmed they do not do their own personal laundry, but the facility staff does it for them. LPA also observed the five (5) residents interviewed to be wearing clean clothing. LPA interviewed nine (9) staff, six (6) out of the nine (9) staff confirmed that they do not know if the washing machines were ever broken because they do not go downstairs. Let it be noted, the laundry room is downstairs. Three (3) out of the nine (9) staff confirmed that one (1) of the washers has not been working but the others do work and there has been no issues doing laundry with one (1) machine working. Furthermore, one (1) of the washers that is not working machine parts were ordered for it on July 09, 2026 and the other three (3) machines are working properly. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide adequate meal portions to residents. It is alleged that residents are not receiving the proper meals because staff do not want to change their diapers. During LPA’s physical tour, LPA took a picture of the food menu and the alternate menu at the entrance of the dining hall. LPA also confirmed the menu and the breakfast they were providing to residents which was French toast, cold cereal and choice of juice, coffee and/or milk which is an adequate breakfast portion. LPA also interviewed five (5) residents that confirmed they do not have an issue receiving extra food if they ask for it. LPA interviewed nine (9) staff that confirmed no residents have complained to them about not receiving adequate meal portions. One (1) of the nine (9) staff stated, “if they ask for seconds they will receive it.” In addition, the Glendale Police Department visited and interviewed residents on 07/08/26 and residents had no complaints about the meal portions. Therefore, based on the interviews conducted, the food menu and food observed the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issue, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 31-AS-20260708124426

Allegation investigated: Staff is physically abusing residents. Staff provides medical care that requires skilled professionals.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility, met with Alise Nazarian, and explained the reason for the visit. --- Staff is physically abusing residents. It was alleged that Staff #1 (S1) pinches Resident #1 (R1) when showering them and slaps R1 when they change their diaper. To investigate the allegation, on February 18, 2026, LPA requested documents and conducted a physical plant tour at around 12:00p.m. From around 1:00p.m. – 3:00p.m., LPA interviewed four (4) staff and five (5) residents. On July 8, 2026, LPA interviewed one (1) additional staff and one (1) additional resident at around 12:00p.m. A review of the Physician’s Report states R1 is able to communicate, able to follow instructions, able to leave facility unsupervised and is not self abusive, disoriented or lack impulse control. (CONT. on LIC9099-C) Unsubstantiated A review of the Care Plan states R1 is suffering from dementia, depression, anxiety and schizophrenia. R1 has episodes of agitation and shouts at staff. A review of the Department’s records does not show an incident report was submitted around the time in question involving S1 and any form of abuse. During the physical plant tour, LPA did not observe signs of distress or abuse. During interviews, two (2) out of five (5) staff stated they overheard that S1 abuses R1 but have never witnessed it. All other staff stated they are not aware of S1 hitting R1 or any other resident. During interviews with residents, all residents stated they are not physically abused by staff. Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff provides medical care that requires skilled professionals. It was alleged that S1 uses needles and injects residents with their insulin and that S1 also pricks their fingers to measure blood sugar levels. To investigate the allegation, on February 18, 2026, LPA interviewed four (4) staff and five (5) residents from around 1:00p.m. – 3:00p.m. On July 8, 2026, LPA interviewed one (1) additional staff and one (1) additional resident at around 12:00p.m. During interviews, all staff, including S1, stated they do not inject resident with insulin or prick their fingers to check glucose levels. The administrator, Alise Nazarian, stated home health nurses are providing services if the resident is unable to perform the task themselves. During interviews, all residents stated they are not aware of S1 or any other facility staff injecting them with needles or checking blood sugar levels. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 31-AS-20260212115722

Allegation investigated: Staff did not make a reasonable effort to assist resident with lost personal belongings.

On 06/01/26, Licensing Program Analyst, (LPA) Raymond Comer, conducted an initial 10-day complaint visit to investigate the above allegation. LPA presented official CDSS identification badge, met with the Administrator, and reason for the visit was disclosed. At 9:25 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, Between 9:45 am and 10:15 am, LPA interviewed the Administrator. Between 10:20 am, and 11:00 am, LPA interviewed three (3) staff. Between 11:05 am, and 12:00 pm, LPA interviewed six (6) residents, including Resident#1 (R1). At 12:30 pm, LPA received and reviewed Facility roster, Personnel roster, Resident#1 (R1's) Physician Report, Appraisal, Resident personal property and valuables inventory log, and other pertinent documentation relevant to this investigation. [LIC9099C] Continued Unsubstantiated Allegation: Staff did not make a reasonable effort to assist resident with lost personal belongings. It was alleged that on 5/13/26, when Resident #1 (R1) was relocated into a different bedroom within the faciltiy, R1 was unable to find a personal belonging (an ATM card) which R1 stated was in his room at the time of the move, and that staff did not assist R1 in locating the missing item. LPA Comer's interview with R1 revealed the following: R1 stated to LPA Comer that he did not report, either to the Administrator, nor any other staff, that their ATM card was missing. Per R1, R1 never requested staff assistance to find their missing ATM card. R1 stated to LPA Comer that several days later, R1 found their ATM card in their wallet, which was stored inside a moving box. LPA Comer observed a video of the 5/13/26 moving event, recorded by staff and approved by R1, which shows that R1 was present with staff during the entirely of the moving event, and shows that all items handled by staff were observed by R1. LPA Comer's interviews with the Administrator, and three (3) staff revealed the following: Both Administrator and staff refute the allegation, stating that R1 never reported missing an ATM card, nor did R1 request any assistance from staff to help locate the missing item. LPA Comer's interviews with six (6) out of a total of fifty-one (51) total residents (including R1) revealed the following: Five (5) out of six (6) residents stated to LPA Comer that staff's safekeeping efforts are adequate and have not witnessed, nor experienced their personal belongings as missing or stolen by any staff or resident of the facility. LPA Comer’s review of available documents did not reveal any information to support the allegation. Based on LPA's conducted interviews, observations, and records reviewe, this allegation is deemed unsubstantiated at this time. Exit interview conducted, and a copy of this report provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 1, 2026 · control 31-AS-20260526081840

Allegation investigated: Facility staff did not safeguard resident's personal belongings

On 05/18/26, at 9:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Alise Nazarian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 05/18/26, LPA Saucedo asked for the census, staff, and resident rosters. On 05/18/26, at 10:20am, LPA Saucedo conducted a physical tour, interviewed both residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Facility staff did not safeguard resident's personal belongings. It is being alleged that resident #1 (R1) moved to a new room and during the move, staff threw away some of their belongings-bed sheets (5 sheet sets with their name written on them in permanent marker) and a green clothing. During LPA's review of the video that was taken during the move on 05/13/26, one (1) of the staff found the sheets that had R1's name in permanent marker and they were handed to R1 in the video. Let it be noted, by looking at the video, the sheets were in the corner of the new room and there was other items but no green clothing was shown. LPA interviewed, four (4) of the staff that helped R1 during the move and all staff stated, "R1's sheets were found during the move but they never saw any green clothing only red clothes." One (1) out of the four (4) staff did state that at the beginning of the move R1 was already asking for that green piece of clothing which was already missing." LPA interviewed four (4) residents that confirmed they have never had any of their personal belongings missing and know where to update their new belongings when they are purchased and/or given to them. During LPA's review of R1's LIC 621 form-Client/Resident Property and Valuable, there is one (1) LIC 621 where R1 refuses to update their LIC 621 form and there is another LIC 621 form dated 02/17/2004 signed by R1 where it just lists clothes but does not specify the green clothing. During LPA 's physical tour of R1's room, the sheets with R1's name were on R1's bed, LPA took pictures of the sheets. During LPA's interview with R1, R1 stated, "the sheets were found but not the green clothing which was missing before the move and does not remember when they went missing and they are still searching for it along with other items." LPA asked R1 if they were present during the moving of rooms and R1 stated, "yes." LPA asked have you updated a LIC 621 form and R1 stated, "not yet, I am still working on it" and agreed to make a new LIC 621 form-Client/Resident Property and Valuable and give it to the staff with their signature. Therefore, based on R1's LIC 621, review of the video of R1's moving room and interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 18, 2026 · control 31-AS-20260514115940

Allegation investigated: Staff did not prevent resident from wandering from the facility Licensee has not posted an updated emergency evacuation plan that includes all resident rooms

On 05/11/26, at 9:10am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Alise Nazarian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 05/11/26, LPA Saucedo asked for the census, staff, and resident rosters. On 05/11/26, at 9:45am, LPA Saucedo conducted a physical tour, interviewed both residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Licensee does not ensure that resident rooms have closets. It is being alleged that resident rooms do not have closets. During LPA's physical tour, LPA observed five (5) rooms to have closets, dressers, televisions, proper lighting. LPA conducted five (5) resident interviews that confirmed they are happy with their room and with the facility. LPA interviewed three (3) staff that confirmed no residents have complained about their room not having proper furnishings. Therefore, based on the interviews and room observations conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Licensee has not posted an updated emergency evacuation plan that includes all resident rooms. It is being alleged that the facility’s posted emergency evacuation plan does not include all rooms. During LPA's physical tour, LPA observed an updated Emergency Disaster Plan against the wall of the facility leading to the left hand entrance of the facility dated 01/10/26 along with the facility sketch. LPA also obtained the facility sketch that shows the 30 rooms in the main building of which some are shared, four (4) of which are for bedridden use room 11 and 28 and the eleven (11) ambulatory rooms in the two (2) cottage areas in the back of the facility. LPA interviewed three (3) staff that stated the rooms have remained the same for over ten (10) through fifteen (15) years since they have been working there and there has been no new construction. LPA also interviewed four (4) out of five (5) residents that stated, "there has been no new construction since they have been living at the facility." One (1) out of the five (5) residents stated, "there was construction maybe fifteen (15) years ago but they cannot remember the exact date, which was changed by the former administrator and does not have any proof." Therefore, based on the interviews, room observations and facility sketch conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 11, 2026 · control 31-AS-20260508150247

Allegation investigated: Staff did not prevent resident from wandering from the facility

On 05/11/26, at 9:10am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Alise Nazarian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 05/11/26, LPA Saucedo asked for the census, staff, and resident rosters. On 05/11/26, at 9:45am, LPA Saucedo conducted a physical tour, interviewed both residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent resident from wandering from the facility. It is being alleged that resident #1(R1) was found outside of the facility to be confused and displaying signs consistent with the need for supervision and care. During LPA's interview with R1, R1 admitted, "that they wanted to take a walk so they exited the facility which R1 had done before and ended up in a construction zone area." LPA asked R1 what their diagnosis was and R1 stated, "I'm bipolar." Let it be noted, R1 was alert and is ambulatory. LPA asked R1 if they are taking their medication and R1 stated, "yes, faithfully everyday." During LPA's file review of R1, R1's Admission Record from the skilled nursing, medical assessment, pre-placement appraisal, needs and services appraisal and resident appraisal confirmed R1 is bipolar, schizophrenic, alert and ambulatory. R1 is not a wanderer and R1 does not have a history of elopement and/or dementia/Alzheimer's. R1's admission date to the facility was on 03/27/26. LPA interviewed two (2) staff that confirmed that R1 is new to the facility and is alert and can walk on their own." One (1) staff did confirm that R1 has a neurologist appointment to make sure R1's diagnosis remains the same and if something is wrong they will update their paperwork and limit R1 from leaving the facility unattended. The other staff stated, "R1 has never refused medication." R1 currently does not need supervision to leave the facility. During LPA's physical tour and observation of R1, R1 was also wearing a wristband that displays the facility name and phone number. Furthermore, LPA received an Unusual/Incident Injury Report that was sent to Community Care Licensing Department in regards to R1's incident on 05/05/26, leaving the facility. LPA interviewed four (4) other residents that do not need help with supervision and stated, "they are free to come and go as they please." Therefore, based on the interviews and file review of R1 conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 11, 2026 · control 31-AS-20260505145705

Allegation investigated: Staff does not provide adequate supervision resulting in resident providing another resident marijuana.

On 4/28/26, Licensing Program Analyst (LPA) Raymond Coomer conducted unannounced subsequent visit to complete an investigation of the above noted allegation. It was reported that on 10/6/2025 staff found marijuana in resident #1 (R1’s) room. R1 admitted it was provided by resident #2 (R2). R1 was using the marijuana only one (1) time. To investigate the allegation, on 10/23/25, LPA conducted an initial complaint visit. During initial visit, at 10:15 am, LPA spoke with the Administrator and discussed the allegations. At 10:40am, LPA requested and received residents’ facility files, including but not limited to physician report, need and service plan, and Medication Administration and Destruction (MAR) records. incident reports, and other pertinent documents; records were reviewed between 11:15 am and 1:00pm. Between 1:10 pm and 1:35 pm, LPA conducted interview with Administrator, two (2) staff that had knowledge of the issue/incident addressed in the complaint. At 1:45 pm, LPA also spoke with three (3) residents including R2 and at 2:05pm, LPA spoke with the witness who had the information regarding the allegation. [LIC9099C] Continued- Unsubstantiated During today’s visit, upon arrival LPA conducted and physical plant tour to inspect the residents' rooms and common areas of the facility; LPA did not witness anyone smoking, nor smelled marijuana anywhere in the facility. At 3:15 pm, LPA requested and reviewed additional facility files including incident reports, and other pertinent records. In addition, at 3:25 pm, LPA interviewed three (03) out of fifty-three (53) residents including resident #1 (R1). LPA Interviews with the Administrator and staff revealed that staff provides required care and supervision to all residents, based on their level of care and needs. Staff indicated that they never witnessed anyone smoking, nor smelled marijuana odor in the facility. According to staff on 10/06/26 staff #1 (S1) was outside of the building and smelled marijuana. S1 observed R2 smoking. S1 approached R2 and R2 admitted smoking marijuana. Furthermore, R1 confirmed they got it from R2. S1 and S2 went and spoke with R2, who admitted giving marijuana to R1. Per Administrator, both R2 and R1 were informed that possession and use of drugs was a violation of house rules which could result in eviction from the facility. LPA interviewed six (6) residents out of a total of fifty-three (53) total residents. Five (5) out of six (6) residents stated that they have never witnessed anyone smoking, nor smelled marijuana odor inside the facility. Information revealed from R1 verified the information received from staff. LPA's review of facility records confirmed that house rules were discussed with R1 and R2. Based on inspection, observation and interviews, it was concluded that although the allegation may have happened, there is not sufficient evidence to confirm that it happened at the facility due to inadequate staff supervision. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate Health and Safety hazard is noted during this visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 31-AS-20251019163417

Allegation investigated: Staff did not provide proper notice of moving to resident

On 04/13/26, at 9:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Alise Nazarian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 04/13/26, LPA Saucedo asked for the census, staff, and resident rosters. On 04/13/26, at 9:55am, LPA Saucedo conducted a physical tour, interviewed both residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not provide proper notice of moving to resident. It is being alleged that resident #1 (R1) received a letter letting them know that they would need to move and it did not include any information regarding who would be moving them, where they would be moving to, or which room they would be placed in. LPA received a copy of R1’s letter stating that they would need to move to the main building dated 04/06/26 because of their current mobility needs and their history of being a fall risk signed by the administrator. During LPA’s interview with R1, R1 admitted that they received a notice with the previous administrator dated April 05, 2022 where it stated, "due to physical health decline, fall risk and poor balance while walking R1 had to be moved to the main building." R1 stated, "I refused to move then." LPA received a copy of the 2022 notice. Additionally, R1 admitted that they were shown a private room in January of 2026 but they did like it because it did not have a shower and they would have to share a shower with others. Let it be noted, R1 is currently living in one (1) of the outside cottages that is for ambulatory residents whom do not require help, and that cottage has a shared bathroom including a shared shower. LPA received the documentation from staff that state, "R1 was offered a private room January 21, 2026 and R1 was shown the room January 29, 2026 and declined the room." During LPA's interview with R1, R1 was observed using a walker and sat on the walker during the interview. R1 was asked by three (3) staff to move to the main building because of R1’s decline in health and R1 has continued to refuse to move. Furthermore, LPA interviewed three (3) staff that have observed R1 requiring a walker to walk. One (1) of the three (3) staff stated, "if R1 does not have the walker, R1 uses the wall for support and walks against the wall." Two (2) of the three (3) staff stated, "I have never seen R1 without a walker and R1 has denied all help from us." LPA obtained an updated resident appraisal dated 03/04/26, and an updated Appraisal Needs and Services Plan dated 01/06/26 which R1 declined to sign that says R1's health has declined and needs help in different areas of Assisted Daily Living. Additionally, LPA received documentation regarding R1's admission to a skilled nursing on 05/15/2024 that states R1 has a history of falling, muscle weakness and needs help bathing, dressing, transfers, toilet use and grooming/personal hygiene. LPA interviewed an additional three (3) residents that reside in the same cottage that R1 currently lives in whom are ambulatory and do not need any assistance walking and they have also observed R1 using a walker daily. LPA interviewed another resident that resides across the cottage in which R1 resides and which is also for ambulatory residents and that resident stated, "no one uses a walker and/or wheelchair in this cottage." Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 31-AS-20260407163830

Allegation investigated: Staff did not ensure medications were dispensed as prescribed

On 3/25/2026 at approximately 10:15 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by the Administrator, Alise Nazarian and stated the reason for their visit. To investigate the allegation(s) at 10:20 AM, LPA requested census, resident and staff roster. At approximately 10:30 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. At 11:00 AM, LPA requested pertinent documentation pertaining to the investigation such as but not limited to: Physician’s Report, Medication Administration Records (MARS) and Staff Schedule. In between 11:00 AM – 1:00 PM, LPA conducted interviews with one (1) resident (R1), three (3) staff members (S1-S3) and conducted record review. (continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not ensure medications were dispensed as prescribed. It was alleged that staff did not administer R1’s medication as prescribed. To investigate the allegation, LPA conducted interviews with one (1) resident and three (3) staff members. LPA’s interview with R1 revealed the morning of 3/13/2026 they did not receive their medication due to staff not being available. R1 stated their prescriptions do not state their medication should be given to them in the timeframes of: morning, afternoon and bedtime, but instead their medication is labeled as “daily”. Additionally, R1 stated they did take their medication upon returning in the afternoon. LPA’s interview with all three (3) staff members confirmed R1 did take their medication on said date. LPA’s interview with S2 revealed, R1 has made it difficult for them to administer their medication due to them wanting their medication at different times of the day. LPA’s interview with two (2) staff members correlated with S2’s interview. When LPA questioned if any staff members dispensing medication were absent during their morning shift on 3/13/2026, all three (3) staff members denied. During LPA’s record review, LPA observed the staff schedule for 3/13/2026. LPA observed both S2 and S3 to be scheduled the morning of said incident. Further record review of R1’s MARs dated 3/13/2026 confirmed their medication was given and signed off. LPA’s supplementary record review of R1’s medication (2/18/2026 to 3/17/2026) revealed that although eight (8) of their medication was observed to be prescribed as “daily”, a web search of all eight (8) medications revealed the medications are advised to be taken in the morning to reduce potential side effects. LPA’s web search of the additional three (3) medications prescribed as (morning, afternoon, evening) revealed said medications could be taken later in the day if not in the morning. During LPA’s physical plant tour, LPA observed R1’s medication to be centrally stored within the locked medication room. LPA did not observe any discrepancy of R1’s medication. Additionally, a complaint was also filed against the facility for the alleged allegation under complaint control number 31-AS-20230621160636 dated 06/21/2023 revealed the findings of the investigation to be unsubstantiated at the time. Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 31-AS-20260319084844

Type of visit: Required - 1 Year

On 03/03/26, at 9:30am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with Alise Nazarian, Administrator and Licensee, Veronica Baher arrived about twenty (20) minutes later. LPA asked for the census, resident, and staff files. The facility has been licensed as a Residential Care Facility for the Elderly. The physical plant was toured inside and outside at 9:50am. It is a single, story home. The facility has twenty-nine (29) resident bedrooms with restrooms, common showers and bathrooms. There are two (2) cottages that are located across the back yard-cottage #1511 and cottage #1515, reserved for ambulatory residents only. The facility has a hospice waiver approved for six (06) residents. The facility is fire cleared for sixty (60) residents of which forty-nine (49) may be non- ambulatory, eleven (11) ambulatory and four (04) may be bedridden. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The facility has cameras in the common areas and is displayed in the main office of the facility at the entrance of the facility. Kitchen is sufficiently stocked with at least seven (07) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and are located downstairs. Knives and sharps are observed to be locked and inaccessible to residents. LIC 809-C-continued There is no special diet for any of the residents. The common and dining areas are neat and clean. The facility maintains a comfortable temperature at 72°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility and observed to be fully charged and last inspected 10/2025. There is one (1) staff room for breaks. There are four (4) patio areas for residents. There is three (3) areas for shared showers. There is an activity room at the entrance of the facility on your right hand side. Random resident rooms were observed. There was adequate furniture with appropriate lighting. Hallways are well lit. Random bathrooms were checked for cleanliness and proper operations and had mats and grab bars. The hot water temperature was measured and varied with temperatures of 116, 115, 113 Fahrenheit. The bathrooms and bedrooms have pull cord alarms for residents. The washer and dryers are located downstairs. The medication room is locked and inaccessible to the residents. Majority of the medication room is bubble wrapped and uses MAR-Medication Administrator Record and Centrally Stored forms. Facility maintains a complete first aid kit. Resident records/Staff records: LPA conducted a complete file review of five (05) resident records. Resident records were complete and updated. Staff records: LPA conducted a complete file review of six (6) staff records. Staff records were complete and updated. LPA reviewed LIC 405 for some residents that have safeguarded cash resources. Administrative: The Insurance plan is dated as of 05/2026. There is a board against the wall that displays-Personal Right, Rights of Resident Council, YES, Ombudsman, Fire Drills have been conducted. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Mar 3, 2026

Allegation investigated: Staff does not ensure facility is in good repair

At approximately 10:30 a.m. on 02/27/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed staff and residents between 10:45 a.m. and 1:00 p.m. today, toured the facility at 11:00 a.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 11:30 a.m. Regarding the allegation "Staff does not ensure facility is in good repair" it was alleged the bathroom near the room of Resident #1 (R1) was missing a towel rack, and the toilet needed a grab bar. LPA observed the bathroom at approximately 11:10 a.m. today and observed the towel rack brackets were present but the bar was missing. LPA observed a grab bar near the toilet. LPA was able to use the grab bar to sit down on the toilet safely. Unsubstantiated Interviews with two (02) other residents who shared the bathroom with R1 revealed they hang their towels over the shower and have no problem with the missing towel rack. They also noted they have no issue with the grab bar. Interviews with four (04) out of four (04) other residents revealed they have no maintenance needs in their rooms or bathrooms. Record review of R1’s most recent medical assessment and care plan revealed they are ambulatory and able to use the toilet and transfer independently. Interview with the administrator at 11:45 a.m. today revealed no residents, including R1, had addressed any maintenance concerns with staff. By 12:00 p.m. today, the administrator had a new towel rack and a commode with grab bars available in the bathroom. Based on observations, interviews, and record review, although the towel rack was missing, residents had sufficient alternative options for drying towels. Also, a grab bar was present near the toilet and the commode with grab bars was available upon request. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 31-AS-20260219144529

Allegation investigated: Staff do not maintain facility clean and sanitary Staff do not provide residents with adequate clothing Staff do not assist residents with grooming Staff do not ensure that residents' dietary needs are met

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility, met with designated administrator, Alise Nazarian, and explained the reason for the visit. --- Staff do not maintain facility clean and sanitary It was alleged that residents’ bedrooms are dusty and smell bad and bathroom walls are dirty and stained. To investigate the allegation, LPA requested documents and conducted a physical plant tour at around 12:00p.m. From around 1:00p.m. – 3:00p.m., LPA interviewed four staff and five residents. During the physical plant tour, LPA did not observe excessive dust, experience malodor or dirty bathrooms. A review of the facility schedule shows two housekeepers present five days a week. During interviews, all staff and residents stated facility is kept clean, free from odor and bathrooms are kept clean. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC9099-C) Unsubstantiated --- Staff do not provide residents with adequate clothing It was alleged that residents do not have enough clothing to change clothes. To investigate the allegation, LPA conducted a physical plant tour at around 12:00p.m. From around 1:00p.m. – 3:00p.m., LPA interviewed four staff and five residents. During the physical plant tour, LPA selected five rooms at random and observed all residents had several clean clothes and facility keeps bins full of new clothing. During interviews, all staff stated all residents have lots of clothes and there are new clothes available should they require. All residents confirmed no shortage of clean clothes or change of clothes. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not assist residents with grooming It was alleged that residents' toe nails are overgrown because they do not get nail care. To investigate the allegation, LPA conducted a physical plant tour at around 12:00p.m. From around 1:00p.m. – 3:00p.m., LPA interviewed four staff and five residents. During the physical plant tour, LPA observed all residents were clean and four out of five were well groomed. The one resident whose nails were long stated it was a choice and feels facility would do it right away if they wanted it. During interviews, all staff stated all residents are groomed and kept clean but that they cannot force residents to stay clean and groomed. All residents confirmed facility offers grooming services and feel they have access to services anytime. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not ensure that residents' dietary needs are met It was alleged that staff do not serve residents vegetables and that the residents are repeatedly served the same meals. To investigate the allegation, LPA requested documents and conducted a physical plant tour at around 12:00p.m. From around 1:00p.m. – 3:00p.m., LPA interviewed four staff and five residents. A review of the facility weekly menu shows that facility serves a variety of well-balanced meals with vegetables. (CONT on LIC9099-C) During the physical plant tour, LPA observed vegetables and leafy greens being served for lunch. During interviews, all staff stated facility serves vegetables with meals and that meals are not repeated. All residents confirmed facility serves vegetables and a variety of options each week. Based on observations, record reviews and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 31-AS-20260212115722

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst, Mary Flores arrived on December 5, 2025 for an unannounced inspection to follow up on a substantiated allegation of complaint investigation. On October 12, 2023, the Department concluded a complaint investigation regarding the following allegations: Staff failed to provide appropriate care and supervision after falls, staff did not provide medical assistance to resident in a timely manner, and insufficient staff to meet the needs of the residents. The licensee was cited for California Code of Regulations (CCR) § Section 87645(a)(1), Incidental Medical and Dental Care, CCR § 87411(a) Personnel Requirements – General, and CCR § 87466 Observation of the Resident. At the time of the complaint visit on October 12, 2023, an immediate civil penalty of $500 was issued, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss of impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision to a resident (R1) after a fall where R1 was left on the floor in a prone position. This position has placed R1 at a risk for pressure injuries, increased chest and abdominal pressure, compressing organs, risk for respiratory complications and blood flow, which could lead to low oxygenation, vomiting, and hypotension. (CONTINUED ON LIC 809C) Today, December 5, 2025 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 12, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Peter Babaian and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: Staff did not ensure a menu was written up at least a week in advance.

On 7/17/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced 10-day complaint visit to the facility to investigate the above allegation. Upon arrival, LPA met with the Administrator Peter Babaian and explained the reason for the visit. Entrance interview conducted. At 10:00am, LPA requested copies of resident and staff rosters. LPA also requested copies of pertinent information which include, but not limited to Facility Program of Operation, copies of weekly and daily meal menu, and a copy of maintenance invoice for the technical issues facility had experienced between 07/04/25-07/07/25. At approximately 10:20am, LPA conducted a physical plant tour to ensure health and safety of the residents are protected. No immediate health and safety hazards were noted during the visit. Between 11:00am – 12:40pm, LPA conducted interviews with the Administrator, assistant Administrator, three (3) staff/caregivers, and six (6) out of fifty-four (54) residents residing at the facility. Continue on 9099-C Unsubstantiated Allegation: Staff did not ensure a menu was written up at least a week in advance. It was reported that the meal menu is not being written up a week in advance by regulations. To investigate the allegation, during today’s visit, LPA interviewed the facility Administrator, assistant Administrator, three (3) staff members, two (2) cooks, and six (6) residents. LPA also reviewed the facility’s weekly and daily menus and observed the current weekly menu posted on the wall next to the dining area. The administrator, assistant Administrator and staff confirmed that weekly menus are prepared and posted in advance. Menu records reviewed during the visit included current and upcoming weekly menus through August 2nd, consistent with the title 22, 87555 (c )(1), which requires menus to be prepared and posted at least one week in advance. Staff also stated that there was a technical issue and 7/4/25 which prevented them printing the following week’s menu. And due to the holiday, the maintenance crew was available on the following day, which was 7/5/25. The work was completed on 7/7/25 and the menu immediately printed out and posted on the wall. Staff provided the work order for technical issue, LPA observed and confirmed that an immediate action was taken. The interview with two (2) cooks also revealed that due to not having access to the following week’s menu, they made a handwritten menu and posted it on the wall for residents. Five (5) out of six (6) residents interviewed stated that they are aware of the weekly menu, know where it is posted, and generally know what to expect for meals ahead of time. Residents also stated that even if any resident is bed bound or for any reason cannot go to the dining area, staff provides the menu to resident’s room. LPA observed the weekly menu posted in the dining area in a visible location accessible to residents. One (1) out of six (6) residents (R1) interviewed stated that although staff have a weekly meal menu available and posted on the wall every week, on Sunday 7/6/25 there was no weekly menu posted, but instead staff had handwritten menu posted for 7/6/25 and 7/7/25. R1 also confirmed that on 7/7/25 the proper weekly menu was available and posted on the wall. Based on observation, interviews, and records review, there is insufficient evidence to support the allegation. Therefore, the complaint is deemed unsubstantiated. No deficiency cited during today’s visit. Exit interview conducted, copy of the report delivered.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 31-AS-20250707114722

Allegation investigated: Staff did not treat residents with dignity and respect

At approximately 10:45 a.m. on 07/09/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the licensee and disclosed the reason for the visit. To investigate the allegations above, LPA De la cerra conducted an initial visit on 12/17/25 and interviewed staff and residents between 2:00 p.m. and 3:15 p.m., conducted a records review at 2:30 p.m., and toured the facility around 3:15 p.m. Today, LPA Reed interviewed three (03) staff and seven (07) residents, which was at least 10% of the total number of residents, between 11:00 a.m. and 2:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 11:15 a.m., and toured the facility inside and out at 11:30 a.m. Substantiated Staff did not treat residents with dignity and respect Regarding the allegation "Staff did not treat residents with dignity and respect" it was alleged S1 yells at residents in a disrespectful manner. Interview with S2 revealed S1 cares for residents but is loud and aggressive. Interviews with Staff #3 (S3) at 12:15 p.m. and Staff #4 (S4) at 12:30 p.m. today revealed they have been treated disrespectfully by S1 and overheard S1 being disrespectful to residents. S3 noted that they reported the issues to the administrator. Record review of S1’s facility file revealed they were given two (02) written warnings for misconduct by the administrator. The first warning was issued on 04/27/22 in which S1 was observed “shouting and verbally abusing” a resident in the shower. The second warning was issued on 02/10/25. The second warning noted that after several warnings, this was to be a final written warning. The warning was issued for “attitude, behavior, and aggressive communications” on 02/07/25 towards a staff and a resident, Resident #2 (R2). Interviews with R2 at 12:40 p.m. and Resident #3 (R3) at 1:10 p.m. today revealed they have both been treated disrespectfully by S1. Based on record review and interviews, multiple residents and staff noted S1’s disrespectful treatment towards residents. The facility is aware of S1’s disrespect and has issued multiple warnings to S1. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is issued on the corresponding LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided. Staff handles residents in a rough manner Regarding the allegation "Staff handles residents in a rough manner" it was alleged Staff #1 (S1) handles residents roughly while assisting with incontinence care. It was reported that yelling was heard from residents who S1 assisted with changing. Interview with Staff #2 (S2) at 11:00 a.m. today revealed they have not received any reports from residents or staff of S1 handling residents in a rough manner or heard any yelling. Interviews with two (02) other staff members revealed they have not heard yelling or any reports of rough handling from S1. Interviews with seven (07) out of seven (07) residents, three (03) of whom receive incontinence care form S1, confirmed they have not been handled roughly by S1. LPA Reed did not observe any rough handling during today’s visit. Based on observations and interviews, there is no evidence indicating S1 handles or handled residents roughly. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Staff steal residents belongings Regarding the allegation "Staff steal residents belongings" it was alleged S1 was seen stealing a resident’s clothes and selling them at a yard sale. Interview with S2 revealed they had not been notified of any theft or staff stealing belongings. Interview with S1 at approximately 1:00 p.m. today revealed they have not stolen any valuables from any residents. S1 noted they have only collected used soda cans for recycling which may have caused someone to think they are stealing. Interviews with Staff #3 (S3) at 12:15 p.m. and Staff #4 (S4) at 12:30 p.m. today revealed they have not witnessed S1 steal resident belongings. Interviews with seven (07) out of seven (07) residents revealed S1 has not stolen anything from them. Based on observations and interviews, there is no evidence to suggest that S1 stole resident belongings. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 31-AS-20241210105657

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 24, 2025

87468.1 Personal Rights... (a) Residents in all residential care facilities for the elderly shall... (1) ...be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by permitting Staff #1 (S1) to be disrespectful towards residents, which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2025

Plan of correction: Licensee to conduct an in-service training to all staff on the cited section and issue a written notice to Staff #1 (S1)

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident leaving the facility unsupervised Facility did not have adequate staff to meet the needs of the residents

***This is an addendum to the Licensing report previously issued on 04/22/2024. The report was updated to provide additional information to support the outcome of investigation.*** At approximately 10:45 a.m. on 07/09/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the licensee and disclosed the reason for the visit. To investigate the allegations above, LPA Valenzuela conducted an initial visit on 04/22/24 and interviewed three (03) facility staff including staff #1 (S1) who assisted a credible witness when they arrived at the facility between 3:30 p.m. and 4:00 p.m. Today, LPA Reed interviewed staff and residents between 11:00 a.m. and 2:00 p.m., conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, the staff schedule for the month of April 2024, and staff and client rosters at 11:15 a.m., and toured the facility inside and out at 11:30 a.m. Unsubstantiated Staff did not provide adequate supervision, resulting in a resident leaving the facility unsupervised. It was reported that on 04/12/24, Resident #1 (R1) left the facility unsupervised and ended up at the hospital. Interviews with the administrator and other staff revealed that the facility is not locked, and the residents can come and go as they please. Staff indicated that on 04/12/2024, R1 left the facility without signing out or notifying staff where they were going. R1 did not return to the facility, and they filed missing person’s report the following day. A review of R1’s facility record revealed that R1 is able to leave the facility unassisted and does not require supervision. Based on interviews and records review, there is insufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Facility did not have adequate staff to meet the needs of the residents. It was alleged that on 04/13/2024, while credible witness visited the facility, there was only one staff member Staff #1 (S1) present and working at the facility to meet all residents’ needs. Interviews with staff and the Administrator revealed that the facility does have sufficient staff to provide care and supervision, as well as to meet the needs of residents in care. Staff revealed that on 04/13/24 when police arrived to the facility due to R1 missing from the facility, there were 3-4 staff present in the facility (2 caregivers, one housekeeper and a cook). Police spoke with S1 only, because S1 was assigned to assist R1. A review of the staff schedule indicated that there were at least three (03) other staff on shift on 04/13/24 (one other caregiver, one server, and a cook). Based on interviews and records review, there is no sufficient information to verify validity of the complaint. Thus, this allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazards were noted at the time of this visit. Exit interview conducted. Copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 31-AS-20240415113140

Allegation investigated: Staff does not ensure the facility’s water temperature is at required range.

On 4/29/2025, Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA Rios met with the Assistant Administrator, Alise Nazarian and explained the reason for the visit. LPA met with the Administrator Peter Babaian shortly after and an entrance interview was conducted. The LPA requested a copy of the register of facility residents (LIC9020) and personnel report (LIC500). LPA Rios conducted interviews from 10:20 a.m to 11:15 a.m. with three (3) staff and five (5) residents. From 11:15 a.m. to 1:12 p.m. LPA Rios conducted a physical plant of the facility inside and out. Regarding the allegation that Staff does not ensure the facility’s water temperature is at required range, it was alleged that the water temperature at the faucet on the back patio of the main building is not being properly regulated. LPA took the hot water temperature from the back patio faucet sink accessible to staff and residents. The hot water temperature read 117 degrees Fahrenheit at 1:12 p.m. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) The facility has three buildings where residents reside. The main building and two other smaller detached buildings. LPA's interview with five (5) out of five (5) residents revealed they did not have concerns about the hot water temperature in the main building or the buildings where they reside. Interview with three (3) out of three (3) staff, the assistant administrator and the administrator stated they had not received complaints from residents, relating to water temperature. Interview with the Administrator revealed the water temperature during this time of year is difficult to control due to the change of the temperature outside. Furthermore, the administrator explained that the water temperature could vary depending on the time of day. For instance, when the kitchen is busiest, the water might feel colder. Given that the patio's outdoor sink is not a sink expected to be used for personal grooming or shaving the hot water coming out of the faucet does not have to be regulated between 105 - 120 degrees Fahrenheit. The outdoor sink was also not observed by LPA to deliver hot water at 125 degree F (52 degree C) or above which would not require a warning sign. The administrator informed LPA Rios that he had placed an order for a warning sign to be installed above the sink, following the discussion about how water temperature tends to vary with the time of year, especially as summer approaches. During the physical plant tour, LPA Rios tested the hot water temperature from five (5) bathroom sinks located in residents' rooms, with readings ranging from 105.4 to 120 degrees Fahrenheit. Based on the information obtained, 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 UNSUBSTANTIATED at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 31-AS-20250425083236

Allegation investigated: Staff mismanaged resident's medication Staff is handling resident roughly

Licensing Program Analyst (LPA) Jose Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. LPA conducted physical plant tour at 10:05 AM, requested copy of facility documents relevant to the investigation at 10:33 AM, interviewed staff and residents between 10:45 AM to 1:00 PM and reviewed records between 1:00 PM to 1:45 PM. Regarding the allegation that Staff is handling resident roughly, it was alleged that Resident #1 (R1)'s leg and arms are being pulled by Staff #1 (S1). LPA's interview with R1 today at 11:30 AM revealed that no staff had touched or hurt R1 and staff take good care of R1. LPA's interview with S1 today at 10:45 AM revealed that S1 was not assigned to R1 and denied touching R1. Further interview revealed that S1 was accused by R1 of stealing R1's stuff about a year ago and had since avoided R1 and only assist R1 when necessary but not on regular basis. (continued to LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with five (5) residents or 10% of the facility’s current census revealed that five (5) out of five (5) residents interviewed did not experience nor witness any staff roughly handling anyone at the facility. Regarding the allegation that Staff mismanaged resident's medication, it was alleged that R1 was over medicated due to R1's medical condition during admission at the hospital. LPA's record review today between 1:00 PM to 1:45 PM revealed that R1 was only given medication as prescribed prior to and after R1's hospitalization. Further review also revealed that the facility had self-reported that R1 was already lethargic the day prior to hospitalization on 02/08/25 but refused to go to the hospital and only agreed to go only on the morning of 02/08/25. LPA's interview with medication staff (LVN) today at 12:00 PM revealed that R1 is medication compliant and they always check with R1's physician whenever there are changes on R1's condition. Based on the information gathered during this visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 31-AS-20250321150140

Allegation investigated: Staff left resident is soiled diapers for an extended period of time. Staff are not meeting resident's toileting needs.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with Administrator, Peter Babaian, and explained the reason for the visit. --- Staff left resident is soiled diapers for an extended period of time. --- Staff are not meeting resident's toileting needs. It was alleged that staff left Resident #1 (R1) in soiled diapers for an extended period of time and are not meeting R1’s toileting needs. To investigate the allegation, on 04/22/2024 LPA Rosaura Valenzuela interviewed staff from 1:30p.m. to 2:00p.m. and reviewed records from 2:00p.m. to 2:24p.m. On 03/16/2025, LPA Duguma conducted a physical plant tour at around 9:30a.m., interviewed three (03) additional staff from 11:00a.m. – 12:30p.m. and six (06) residents from around 1:00p.m. to 2:30p.m. (CONT. on LIC9099-C) Unsubstantiated During the physical plant tour, LPA observed that all residents were clean, well-groomed and did not experience any malodor. A review of R1’s Physician’s Report revealed that R1 is incontinent and can communicate their needs. During interviews with staff, all staff stated residents are not left soiled for an extended time and all incontinent residents are checked on every two hours and changed as needed. Staff #1 (S1) added R1 wears more than one diaper at a time due to their large frame. S1 states that R1's diaper is constantly changed throughout the day and that they are given a bath three (03) times per week. While at the hospital R1 was found to have a urinary tract infection (UTI). R1 is able to communicate their needs and they did not notify staff that their diaper was wet and needed to be changed. During interviews with residents, all residents stated they are not left soiled for an extended time and that staff check on them on average every two (02) hours. LPA was unable to interview R1 at the time of the visit. Based on observations, interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 16, 2025 · control 31-AS-20240418090205

Allegation investigated: Staff physically abused resident while in care. Staff did not treat resident with dignity and respect. Due to lack of supervision resident wandered away from facility.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with administrator, Marisol Borrero, and explained the reason for the visit. LPA Duguma spoke with the Administrator, Peter Babaian, who designated Marisol Borrero to sign and accept the report. --- Staff physically abused resident while in care. It was alleged that facility harasses and hits resident. To investigate the allegation, on 03/13/2024 LPA Rosaura Valenzuela interviewed staff from 10:45a.m. to 11:15a.m. and reviewed facility documents from 11:30a.m. to 12:00p.m. On 03/15/2025, LPA Duguma conducted a physical plant tour and requested documents at around 9:30a.m., interviewed three (03) additional staff from 11:00a.m. – 12:30p.m. and six (06) residents from around 1:00p.m. to 2:30p.m. (CONT. on LIC9099-C) Unsubstantiated During the physical plant tour, LPA observed that all residents were clean, well-groomed and did not show signs of physical abuse. Record review revealed that R1 has a history of self-harming behavior. A review of the Department’s Incident Report records did not show that resident had any wandering incidents or physical incidents with staff. During interviews with staff, all staff stated R1 has never had a physical altercation with them or know of any other staff that has harassed or hit R1. During interviews with residents, all residents stated staff do not harass or hit them. Based on observations, interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. ---Staff did not treat resident with dignity and respect. It was alleged that facility staff are evil people. To investigate the allegation, on 03/13/2024 LPA Rosaura Valenzuela interviewed staff from 10:45a.m. to 11:15a.m. and reviewed facility documents from 11:30a.m. to 12:00p.m. On 03/15/2025, LPA interviewed three (03) additional staff from 11:00a.m. – 12:30p.m. and six (06) residents from around 1:00p.m. to 2:30p.m. Records revealed that R1 has a history of multiple psychiatric hospitalizations. During interviews with staff, all staff stated they treat all residents with dignity and respect. During interviews with residents, all residents stated staff treat them with dignity and respect. LPA was unable to interview R1 as they were not in the facility at the time of the visit. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. --- Due to lack of supervision resident wandered away from facility. It was alleged that R1 eloped from the facility. To investigate the allegation, on 03/13/2024 LPA Rosaura Valenzuela interviewed staff from 10:45a.m. to 11:15a.m. and reviewed facility documents from 11:30a.m. to 12:00p.m. On 03/15/2025, LPA Duguma conducted a physical plant tour and requested documents at around 9:30a.m., interviewed three (03) additional staff from 11:00a.m. – 12:30p.m. and six (06) residents from around 1:00p.m. to 2:30p.m. A review of the facility logbook shows that R1 left the facility without signing out. (CONT. on LIC9099-C) A review of R1’s Physician’s Report revealed that resident is able to leave the facility unassisted. A review of the Department’s Incident Report records did not show that resident had any wandering incidents. During interviews with staff, Staff #1 (S1) stated Residents are free to come and go as they please. S1 added on 2/19/24, R1 left the facility and did not use the sign out book. After 24 hours had passed, S1 contacted the Glendale Police Department and filed a missing person's report. S1 stated R1 returned to the facility on 3/04/24. All other staff stated to their knowledge, R1 is able to leave the facility unassisted. LPA was unable to interview R1 as they were not in the facility at the time of the visit. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 15, 2025 · control 31-AS-20240305113301

Allegation investigated: Staff physically abused a resident

At approximately 10:30 a.m. on 03/11/2025 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA interviewed staff and residents today between 10:40 a.m. and 2:40 p.m., conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 11:00 a.m., and toured the facility inside and out at 11:15 a.m. Regarding the allegation "Staff physically abused a resident" it was alleged Staff #1 (S1) struck Resident #1 (R1) in the face twice. Interview with the administrator at 10:40 a.m. today revealed they were aware of the allegation and reported it to the Department. Glendale police investigated the allegation on 03/10/2025. Substantiated The administrator noted that a previous incident occurred between R1 and S1 in January 2025. No injuries were observed on R1 after the incidents, but the administrator issued a warning to S1. Interview with R1 at 12:00 p.m. today revealed S1 “socked [them] in the face”. Interview with Resident #2 (R2) at 12:10 p.m. today revealed they witnessed the alleged abuse. R2 stated S1 was assisting R1 in transferring from their bed to their wheelchair when R1 slipped. S1 then hit R1 and shoved them back onto the bed. Interview with Staff #2 (S2) at 12:25 p.m. today revealed S1 has abused residents in the past. S2 reported the abuse to their supervisors. Interview with Resident #3 (R3) at 12:40 p.m. today revealed S1 is physically and verbally “rough with residents” and has pushed them on two previous occasions. Interview with Resident #4 (R4) around 1:20 p.m. today confirmed S1 is “rough” with residents. Interview with S1 at 2:10 p.m. today revealed they have a difficult time working with R1 because they often resist care. S1 stated they never abused R1 and that R1 and R2 are dramatic. Based on interviews and record review, there is sufficient evidence to confirm that S1 physically abused R1. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the LIC 9099-D page. An immediate civil penalty of $500 is issued on the LIC 421IM page for the physical abuse of a resident. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 31-AS-20250310162358

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 12, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall... (3) ...be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not met as evidenced by: Based on record review and interview, the licnesee did not comply witht he section cited above in allowing Staff #1 (S1) to hit Resident #1 (R1) which posed an immediate Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: The licensee has agreed to suspend Staff #1 (S1) until they complete further investigation into the abuse and will ensure S1 does not come into direct contact with residents.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Peter Babaian for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:30 AM and the following was noted: There is one visitor's entrance being utilized at the facility. The facility has twenty-nine (29) resident bedrooms with restrooms, common showers and bathrooms. The cottages are located across the back yard and each have four (04) bedrooms with a shared bathroom. The facility is fire cleared for sixty (60) residents of which forty-nine (49) may be non- ambulatory and four (04) may be bedridden in rooms #11 and 28. The property also has two (02) cottages, #1511 and 1515, reserved for ambulatory residents only and has a hospice waiver approved for six (06). The facility is currently occupying fifty-three (53) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. (continued on LIC 809-C) The common and dining areas are neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility and observed to be fully charged and last inspected 09/27/2024. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at an 115.3°F. Towels and washcloths are not shared. There was enough clean linen available. LPA observed medication room to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff do not ensure that menu is available for review by residents-

On Monday, 12/23/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced 10-Day initial complaint visit regarding the allegation listed above. At 9:00 am, LPA presented California Department of Social Services Identification badge to facility Administrator, Peter Babaian, and the purpose of the visit was disclosed. A physical plant tour of the facility was conducted. No health and safety issues were observed. Allegation: Staff do not ensure that menu is available for review by residents- It was alleged that staff did not ensure menu was made available to residents in care. [LIC 9099C] Continued Unsubstantiated To investigate the allegation, LPA received facility resident roster, and staff roster. At 9:40 am, LPA conducted a review of Resident 1's (R1's) file, and other documents relevant to the investigation. Between 10:20 am, and 11:10 am, LPA interviewed the Administrator, and Food Service Staff. Between 11:30 am and 12:40 pm, LPA interviewed four (4) Residents, and attempted to contact R1's Responsible Family Member (F1), via cellphone. LPA interview with Administrator revealed the following: On Saturday, 12/14/24, the facility's internet and printer were offline; as a result, staff were unable to print out the menu for the following week. In the interim, the Administrator, and kitchen staff, spoke to all residents and provided them menu information until the new weekly menu was posted. Administrator states that printer issues were resolved in less than 48 hours, and facility's food menu was printed/posted on Monday morning, 12/16/24. LPA interview with Staff revealed the following: Administrator informed kitchen staff of printer problems and told staff to communicate food menu information to all residents until further notice. LPA interview with Residents revealed the following: Residents (R2 through R4) state that facility staff communicated to residents they were temporarily unable to print the weekly menu at the time, and communicated next week's food menu information to residents. Finally, residents state that the new weekly food menu was made available and posted on Monday morning,12/16/24. Based on observation, interviews, and records review, there is not sufficient information to verify the allegation that staff are negligent in ensuring food menu is available for review by residents. Therefore, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 31-AS-20241219161703

Allegation investigated: Resident’s personal belongings are being stolen at facility. Staff are not properly addressing pest infestation in facility.

Licensing Program Analyst (LPA) Leizl de la cerra conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with administrator, Peter Babaian, and explained the reason for the visit. Regarding the allegation: Resident’s personal belongings are being stolen at facility. It was alleged that R1's tupperware with a lid and two (2) cereal bowls were stolen by a staff member. To investigate the allegation, on 11/12/2024, LPA conducted a physical plant tour, reviewed pertinent documents and interviewed three (03) staff members and interviewed six (06) residents between 10:30PM to 2:55PM. LPA's record review today revealed that R1 did not declare the tupperware with lid and two (2) cereal bowls on their signed Client/Resident Personal and Valuables (LIC 621) document. LPA's interview with five (5) residents today also revealed that all five (5) residents did not have any of their personal belongings stolen while living at the facility nor expressed any concerns of any belongings being stolen. CONTINUE to LIC9099C Unsubstantiated During interviews with R1, they stated the tupperware with lid and the 2 cereal bowls were not actually stolen but the items were possibly thrown away by a staff member who could be concerned of the food being old or spoiled. R1 also informed LPA that R1 deducted $15.48 from his monthly rental payment of $1,398.07 to cover the expenses R1 incurred. The expenses R1 incurred was for a 2 bowls and a cockroach bug spray. LPA was provided a copy of R1's payment in a form of a check to the facility, Victor Royale in the amount of $1,382.59, which is $15.48 less. The administrator (S1) informed LPA that there was no objection on their part towards R1 for paying a reduced amount on their rent. LPA interview with three (03) staff members and revealed that two (02) out of three (03) staff members have concerns about some residents leaving open containers with food that could potentially result to having ants and cockroach infestation in the facility. S1 and S3 reveals that LA County Public Health and the pest control company advised facility house keepers that if there are any containers found in any resident's rooms that contains old or spoiled food that the staff has to dispose or discard the container to prevent any pest infestations. Based on observation, interviews and record reviews, there was not enough supporting information to confirm the allegation. Therefore, the allegation deemed unsubstantiated at this time. Regarding the allegation: Staff are not properly addressing pest infestation in facility. It was alleged that staff are not properly addressing pest infestation in facility. To investigate the allegation, on 011/12/2024, LPA conducted a physical plant tour, reviewed pertinent documents and interviewed three (03) staff members and interviewed six (06) residents between 10:30PM to 2:45PM. LPA's interview with the administrator, S1 stated that none of the residents have stated of any problems with cockroaches or ants. S1 said that the facility has a contract with a pest control service, and the pest control service comes to the facility twice a month to monitor, inspect and resolve any pest problems. S1 provided LPA a copy of the inspection report from the pest control company for the month of November, 2024 and inspection report does not reveal that there was any infestation. LPA's interview with five (5) residents and all five (5) residents informed LPA that no cockroaches or ants were observed in their bedrooms. All five (5) residents also informed LPA that there were no ants observed in the bathroom. LPA conducted a physical plant tour of the facility and specifically a tour at the bungalow/cottage #1511 that has 5 rooms and one (1) bathroom. LPA did not observe any cockroaches or ants in all five (5) rooms and did not observe any cockroaches or ants in the one (1) bathroom. Based on observation, interviews and record reviews, there was not enough supporting information to confirm the allegation. Therefore, the allegation deemed unsubstantiated at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued to administrator.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 31-AS-20241104120214

Allegation investigated: Licensee is not ensuring that facility license is posted in a prominent location in the facility accessible to public view.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that Licensee is not ensuring that facility license is posted in a prominent location in the facility accessible to public view. To investigate this allegation on 9/25/24, between 11:00am and 11:20am, LPA conducted a physical plant tour. During the physical plant tour, LPA did not immediately see the facility license posted in the facility, but after speaking to staff, they pointed out that the facility license is posted inside the assistant administrator's office whose door is open and the windows are clear. LPA observed the license along with other certificates there. Between 11:30am and 12:15pm, LPA initiated staff interviews. Interviews revealed that the license has been posted inside the assistant administrator's office for over ten years and that another copy was posted inside the Licensee's office. Last week it was removed, because the office was painted and the Licensee has decided to purchase a new frame. During today's visit, the administrator posted a copy of the license in front of the Licensee's office which is located near the entrance. Unsubstantiated Based on observation and interviews, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 31-AS-20240919171150

Allegation investigated: Facility signal system is not consistently functional.

Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced initial complaint visit to the facility. Upon entry, LPA was met with the Executive Director, Peter Babaian, and explained the reason for the visit. Facility signal system is not consistently functional.. It was alleged that R1's signal system is not consistently functional. To investigate the allegation, on 09/16/2024 at 11:30AM, LPA conducted a physical plant tour, interviewed two (02) staff members and interviewed one (01) resident between 12:30PM to 2:00PM. Before conducting the physical plant tour, staff member #1, S1 showed LPA how the signal system works within the facility. LPA observed that the front desk of the facility where a staff member is always available/present monitoring the equipment that receives the signal system when activated by a resident of the facility. The screen of the equipment shows the staff member which room the signal system alert is coming from. CONTINUE to LIC9099C Unsubstantiated During the physical plant tour LPA observed that R1's room is in a cottage that consist of 5 bedrooms. R1 is in bedroom #4. LPA with the assistance of a staff member #2, S2 pushed the switch of the signal system in R1s room (room #4), a staff member #3, S3 who was at the front desk, received the signal and headed over R1's room. LPA took notice that S3 showed up at R1's room within a minute. Furthermore, LPA sat at the front desk and requested S2 to go back to the cottage and had S2 push the signal system for two other bedrooms that are in cottage #1515. S2 pressed the signal system for bedroom #2 and bedroom #5, LPA observed that both alerts registered on the screen of the equipment. LPA visually observed that the receiving equipment showed that the signal system was alerted from bedroom #2 and bedroom #5. LPA interviewed staff member #1, S1 and S1 interview revealed that R1 complained about the signal alert problem, R1 was informed by S1 on 9/10/24 that the company that maintains the signal system (HCI Systems, Inc,) was called to check for any problems with the signal system within the cottage #1515. S1 was informed by HCI Systems during a remote maintenance check that there was no record of any disfunction with the call systems. S1 then relayed that information to R1. S1 also requested HCI systems, Inc. to do a physical maintenance system check to ensure R1 that all call systems were functional in cottage #1515, Based on observation, interview and record reviews, there was not enough supporting information to confirm the allegation. Therefore, the allegation deemed unsubstantiated at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued by e-mail to administrator due to technical issues.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 31-AS-20240906090906

Allegation investigated: Staff financially abused resident.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with administrator, Peter Babian, and explained the reason for the visit. ---Staff financially abused resident. It was alleged that Staff #1 (S1) took Resident #1’s (R1) card and withdrew money from the account without permission and that R1 is unable to locate the card. To investigate the allegation, LPA interviewed two (02) staff between 11:30 AM to 12:15 PM. On 09/04/2024 at around 11:30 AM, LPA requested documents and at 1:45 PM LPA interviewed R1. A review of R1’s ledger shows a positive balance of $2400.00. During interviews with staff, S1 stated R1 reported to staff that they lost their card. S1 called the agency and the representative stated they processed a replacement card. (LIC 9099-C) Unsubstantiated S1 added when the agency representative showed R1 what the card looked like, R1 said they have the card but by then it was too late because the new card was already being processed. Staff #2 (S2) added R1 stated they have $2800.00 cash in the room and S2 explained the dangers of keeping such a large amount. R1 later decided to keep $400.00 and gave S2 the remaining $2400.00 to register on the ledger for safekeeping. During interviews with R1, they stated the card was not lost or stolen and had it the whole time but now has a new card. R1 stated they do not suspect that S1 took the card and withdrew money. R1 stated they do not suspect fraud and their money is not missing. R1 added they withdrew the $3000.00 themselves and kept it in their room but gave staff $2400.00 for safekeeping in their resident facility based account. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 31-AS-20240809150146

Allegation investigated: Unknown adult in facility sent inappropriate pictures to resident.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with administrator, Peter Babian, and explained the reason for the visit. ---Unknown adult in facility sent inappropriate pictures to resident. It was alleged that a staff or resident sent Resident #1 (R1) inappropriate pictures. To investigate the allegation, LPA interviewed four (04) staff and six (06) residents between 11:15 AM to 3:30 PM. During interviews with staff, Staff #1 (S1) stated R1's responsible party contacted the facility and reported R1 receiving inappropriate pictures from unknown staff. S1 added they discussed the allegation with the suspected staff and staff denied sending any pictures to R1. (CONT. on LIC9099-C) Unsubstantiated S1 stated Staff #2 (S2) does not have a history of such behavior at the facility. During interviews, S2 denied sending the alleged inappropriate picture to R1. All other staff stated they are not aware of any residents or staff sending or receiving inappropriate pictures. During interviews with residents, R1 stated they do not know the name of the staff and only knows they go by “O”, has a relative currently working in the facility and they exchanged contact information about two weeks ago. R1 added S2 allegedly asked to marry R1 and then sent a picture of their genitalia. All other residents stated they are not aware of any residents or staff sending or receiving inappropriate pictures. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 31-AS-20240829110911

Allegation investigated: Staff are not providing comfortable temperatures for residents Staff did not ensure the porch had hand railings Staff did not ensure doorhandle was not in disrepair resulting in injury

On 07/01/24, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Peter Babaian. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 06/27/24, Licensing Program Analyst (LPA) Tuesday Cabiness initiated the complaint investigation. On 07/01/24, LPA Saucedo asked for the census, staff, and resident roster. On 07/01/24, at 10:15 LPA Saucedo conducted a physical tour and interviewed residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff are not providing comfortable temperatures for residents. It is being alleged that the new cottage/building has air conditioning but the old cottage/building does not have air conditioning except for the living room area. Five (5) out of five (5) residents confirmed that the old cottage/building does not have air conditioning but the living room does have air conditioning. Four (4) out of five (5) residents confirmed that the temperatures are comfortable for them. Three (3) out of three (3) staff confirmed that the old cottage/building does not have air conditioning but the living room does have air conditioning including some residents have their own portable air conditioner. During LPA's physical tour, LPA entered several rooms in the old cottage/building and several residents had their individualized, portable air conditioner and/or fan. In addition, LPA observed the temperature throughout the cottage/building hallways to be within Title 22 regulations. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure the porch had hand railings. It is being alleged that the new cottage does not have hand railings which is a hazard. Four (4) out of five (5) residents confirmed that the hand railings which is located in the new cottage/building does not have hand railings but it does not affect them due to them being ambulatory. Three (3) out of three (3) staff confirmed that the new cottage/building does not have hand railing but does have a ramp located in the back. During LPA's physical tour, LPA observed that the new cottage/building does not have any hand railings and it does not possess a hazard due to all residents being ambulatory including the residents that reside in that cottage. The new cottage/building also has a ramp located in the back. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure doorhandle was not in disrepair resulting in injury. It is being alleged that the doorhandle is in disrepair injuring one (1) of the residents. Four (4) out of five (5) residents confirmed that the doorhandle which is located in the main building is not in disrepair and has not caused any injuries to anybody. Three (3) out of three (3) staff confirmed that the doorhandle which is in the main building is not in disrepair. During LPA's physical tour, LPA observed that the doorhandle in the main building was not in disrepair. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 1, 2024 · control 31-AS-20240621085112

Allegation investigated: Staff did not maintain the hot water temperature

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit to address the allegation mentioned above. LPA met with Licensing Vocational Nurse (LVN) Amy Smbatuni who was informed the reason of the visit. Administrator Peter Babaian arrived later and was made aware of the visit. The following information was obtained: It was alleged staff did not maintain the hot water temperature. During the visit, from 930am to 130pm, LPA conducted a physical plant inspection, and interviews. LPA measured the hot water in several rooms, including the outside sink, located on the patio. The temperatures ranged from 102.0 to 125.6 degrees Fahrenheit. According to Title 22 regulations, hot water must be between 105.0 and 120.00 degrees. During the visit, the water was adjusted, and LPA retested the temperature, and it was measured at 120.0 degrees. This could be a potential health and safety risk to residents in care in care. Therefore, based on the physical plant inspection, the allegation is Substantiated, and the plan of correction was cleared during the visit. No further action needs to be taken, water in compliance. Exit interview and copy of report provided. Substantiatedthe state’s words, verbatim · CDSS document, Jun 27, 2024 · control 31-AS-20240626084154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jun 27, 2024

Maintenance operation: (e) Water supplies and plumbing fixtures shall be maintained as follows:(2 Faucets used by residents for personal care such as shaving and grooming shall be...maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of... ... not less than 105 degree F...and not more than 120 degree F...This requirement was not met, evidenced by; based on water temperature ranged from 102.0 to 125.6 degrees. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Plan of Correction completed during the visit. Water was adjusted and re-tested. LPA measured water at 120.0 degrees, which is in compliance.

Allegation investigated: Staff are not treating residents with dignity and respect.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff are not treating residents with dignity and respect. Resident #1 (R1) is alleging that they are constantly being yelled and screamed at by Staff #1 (S1). To investigate this allegation on 06/12/2024, between 2:15pm and 2:45pm, staff interviews were initiated. Interviews revealed that S1 does yell at R1. R1 and S1 do not get along. Facility staff also have issues with S1. They told LPA that S1 does yell at residents and is rough with them when changing their diaper or bathing them. Residents can be heard screaming and crying according to staff. Between 2:45pm aBnd 3:15pm, LPA spoke to R1. Interviews revealed that S1 yells and screams all day. S1 uses profanity and does not get along with facility residents or staff. Between 3:20pm and 3:35pm, LPA heard S1 yelling at residents who were about to be showered. Continue on C-9099 Substantiated Based on interviews and observation there is sufficient information to support this allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to the California Code of Regulations, Title 22, the following deficiency was observed and cited during this visit. No other health and safety hazards are noted during this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 31-AS-20240611095851

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 26, 2024

87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilties for the elderly shall...(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: LPA observed S1 yelling at residents who were about to shower. Staff and R1 also stated the R1 yells at residents in care. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: The Licensee shall submit in writing to Licensing by 06/25/24, how they will ensure that all residents in care are treated with dignity and respect.

Allegation investigated: Resident fell due to staff neglect Staff did not ensure the floors were not in disrepair

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unnounced visit for the above noted allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that a Resdient fell due to staff neglect. Resident #1 (R1) had an unwitnessed fall while using a wheelchair. To investigate this allegation on 06/05/24, between 1:15pm and 1:45pm, staff interviews were initiated. Interviews revealed that R1 can walk on their own, but prefers to use a wheelchair. On 06/03/24, the day of the fall, R1 did not ask staff for assistance to enter or exit their room, nor did anyone witness the fall. Staff assesed R1 and determine that no injuries were sustained.. Between 1:45pm and 2:10pm, facility records were reviewed. Records revealed that R1 is ambulatory, but due to their physical condition uses a wheelchair at times. LPA attempted to speak to R1, but could not since they were upset, yelling, and using profanity. Based on interviews and records review there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Unsubstantiated It was alleged that Staff did not ensure the floors were not in disrepair. To investigate this allegation, on 06/05/24, between 1:15pm and 1:45pm, staff interviews were initiated. Interviews revealed that a new floor is being installed. The previous floor had gaps and that is why it was removed. Facility notified verbally all residents and Licensing that a new floor was going to be installed. Between 2:20pm and 2:45pm, LPA walked around the facility. LPA observed that a new floor was being installed and did not see any holes or debris on the floor. The new floor did not look like it was in disrepair. The person installing the floor said the work would be completed by today, 06/05/24. Based on interviews and observation, there is not sufficient information to support this allegation. Hence, the allegation, is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 5, 2024 · control 31-AS-20240604082740

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident leaving the facility unsupervised. Facility did not have adequate staff to meet the needs of the residents.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff did not provide adequate supervision, resulting in a resident leaving the facility unsupervised. On 4/13/2024, Resident #1 (R1) went AWOL from the facility and checked themselves into a hospital. On 4/22/2024, between 3:30pm and 4:00pm, staff interviews were initiated. Interviews revealed that facility is not locked and that residents can come and go as they please. On 4/13/2024, R1 left the facility without signing out or notifying staff where they were going. Between 4:00pm and 4:30pm, facility records were reviewed. Records confirmed what staff had told LPA. Based on interviews and records review, there is sufficient information to not support this allegation. Therefore, this allegatio is UNSUBSTATIATED at this time. Continue on 9099-C Unsubstantiated It was alleged that facility did not have adequate staff to meet the needs of the residents. To investigate this allegation on 4/22/24, between 3:30pm and 4:00pm, staff interviews were initiated. Interviews revealed that facility does have sufficient staff to provide care and supervision, as well as to met the needs of residents in care. On 4/13/2024, it was reported that there was only one caregiver present at the facility. Staff interviews revealed that there are at least two caregivers present per shift. If staff were changing shift, it was possible that only one staff was present at that moment. Moreover, facility is in the process of hiring more staff. Between 4:00pm and 4:30pm, facility records were reviewed. Records confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to support this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 31-AS-20240415113140

Allegation investigated: Staff left resident in soiled diapers for an extended period of time. Staff are not meeting resident's toileting needs.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff left resident in soiled diapers for an extended period of time. To investigate this allegation on 4/22/2024, between 1:30pm and 2:00pm, staff interviews were initiated. Interviews revealed that Resident #1 (R1) is incontinent and wears more that one diaper at a time due to their large frame. Furthermore, Staff #1 (S1) denies that R1 was left in soiled diapers for an extended period of time. S1 states that R1's diaper is constantly changed throughout the day and that they are given a bath three times per week. R1 is currently out of the community and was recently sent to a skilled nursing facility after a recent hospitalization. While at the hospital R1 was found to have a urinary tract infection (UTI). R1 i able to communicate their needs and they did not notify staff that their their diaper was wet and needed to be changed. Continue on 9099-C Unsubstantiated Between 2:00pm and 2:24pm, facility records were reviewed. Records reviewed confirmed what staff had told Licensing. R1 is incontinent and can communicate their needs. Based on interviews and records review there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It alleged that Staff are not meeting resident's toileting needs. Between 1:30pm and 2:00pm, staff interviews were initiated. Interviews revealed that R1 is provided assistance with their toileting needs. Staff provide R1 with diapers and change them as needed. In addition, R1 is able to communicate their needs. Further, between 2:00pm and 2:24pm, facility files were reviewed. Records confirm what staff told LPA. Based on interviews and records review there is not sufficient information to support this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. No health or safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 31-AS-20240418090205

Allegation investigated: Staff did not seek, medical attention after the resident suffered significant injuries.

On 4.9.2024 Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Raymond Comer arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Peter Babaian (S1) who is the administrator of the facility. At 10:45 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care. Allegation: Staff did not seek medical attention, after the resident suffered significant injuries. Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Raymond Comer conducted a subsequent complaint visit. Regarding the allegation above it is alleged that staff did not seek medical attention after the resident suffered significant injuries. Continue to LIC 9099-C Unsubstantiated On 03.20.2024 LPA Leslie Ngo-Castaneda initiated this investigation into the complaint. LPA requested and reviewed the staff roster, resident roster, residents’ physician’s report, admissions agreement, appraisals, and incidents reports. On 3.22.2024 and 3.26.2024 LPA requested medical documents from Glendale Memorial Hospital. Medical records were reviewed on 3.26.2024 and 3.29.2024. It was alleged that R1 had fallen in their bedroom (room 6) and was unconscious for three (3) hours. R1 stated that they were at the hospital for three (3) days and that a CT scan was done and revealed that their nose was broken, their jaw was dislocated, and multiple spine bones were injured. To investigate the complaint, LPA interviewed twelve (12) out of fifty-three (53) residents. LPA also interviewed seven (7) out of seventeen (17) staff . During the interview with residents, all the residents stated that their medical needs are attended to; if higher care is needed by the residents it was advised to LPA that 911 would be called or the facility would take residents to the emergency room (ER). R1 is compliant with all their medications given at the facility. During the interview with the residents, all of them stated that they have no complaints regarding their medical needs, and everyone is satisfied. During the interview with staff, it was revealed that S2 and S6 stated that R1 would tend to complain a lot about being in pain just to ‘obtain a prescription, especially during the weekends'. According to staff, since R1 assumes that their medical care is being ignored, R1 would just roll themselves in their wheelchair to the emergency room, which is just across the street, Glendale Memorial Hospital. On March 22, 2024, and March 27, 2024, LPA received medical records from Glendale Memorial Hospital. R1 was at the ER with the following dates: 2.9.2024, 2.18.2024, 2.21.2024, 2.24.2024, 2.25.2024, 2.28.2024, 3.14.2024, 3.16.2024 (R1 left without being seen), and 3.19.2024. LPA reviewed records from February until March 27, 2024, there is NO indication that R1 was in the hospital as an inpatient. No records indicated that CT was done on any injuries to any of R1 body parts. Records indicated that R1 goes to the ER because of ‘body pain’ because of fibromyalgia. Based on the interviews and record review obtained, this allegation is therefore unsubstantiated. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 31-AS-20240320104246

Type of visit: Case Management - Deficiencies

On 4.9.2024 Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Raymond Comer conducted a subsequent complaint investigation at the above facility regarding complaints #31-AS-20240320104246. LPAs Leslie Ngo-Castaneda and Raymond Comer were met by the Administrator, Peter Babian. During the facility tour at 10:45 AM, LPAs noticed that the flooring were cracked and duct tape was placed in multiple areas within the hallways of the facility. The Administrator and staff admitted that there are cracks and broken flooring within the facility. Based on LPA's observation, this can cause an unsafe and hazardous walkway for the residents. The Administrator stated they had informed the owner of flooring being in disrepair. Administrator stated that they are replacing the flooring to carpet. Based on the observation of LPAs deficiencies will be issued in LIC 809-D. Based upon the Title 22 regulations, the following deficiencies have been issued. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Apr 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 23, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation and interview the licensee failed to ensure complete safe walkway flooring with the facility for residents in care which poses a possible health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2024

Plan of correction: Administartor will send a picture when floorings are change and replaced.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit for the purpose of obtaining additional documents pertaining to complaint report #: 28-AS-20220510135636 (5/10/22). The purpose of the visit was explained to Assistant Administrator Alise Nazarian. Administrator Peter Babaian arrived towards the end of the visit. LPA requested staff file documents but was informed by Assistant Administrator that Administration staff in charge of the facility when Administrator is not present do not have access to staff training records. During today's visit LPA conducted a physical plant tour of the facility and obtained the following records: Staff (S1 & S2) personnel and training records. No health and safety issues were observed during today's physical plant tour. Exit interview conducted and a copy of this report was issued to Administrator Peter Babaian.the state’s words, verbatim · CDSS document, Apr 2, 2024

Allegation investigated: Staff physically abused resident while in care Staff did not treat resident with dignity and respect Due to lack of supervision resident wandered away from facility.

Licensing Program Anaylsts (LPAs) Rosaura Valenzuela and Leizl De La Cera conducted an unannounced visit for the above noted allegations. LPAs met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff physically abused resident while in care. It was alleged that Resident #1 (R1) was hit by unidentifed facility staff. To investigate this allegation on 3/13/2024, between 10:45am and 11:15am, staff interviews were initiated. Interviews revealed that R1 is not physcially abused by staff. In addition, R1 never reported to the Administrator that facility staff were hitting them. LPA could not interview R1 because they were out of the community. Between 11:30pm and 12:00pm, LPA reviewed facility records. Records revealed that R1 has a history of self-harming behavior. Based on interviews and records review there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Unsubstantiated It was alleged that staff did not treat resident with dignity and respect. It was reported that R1 was harassed by unidentified facility staff. Between 10:45am and 11:15am, staff interviews were initiated. Interviews revealed that R1 is not harassed by staff. All residents are treated with dignity and respect. Furthermore, R1 never reported to the Administrator that facility staff were harassing them. LPA could not interview R1 because they were out of the community. Between 11:30pm and 12:00pm, LPA reviewed facility records. Records revealed that R1 has a history of multiple psychiatric hospitalizations. Based on interviews and records review, there is not sufficient information to support this allegation. Thus, the allegation is UNSUBSTANTIATED at this time. It was reported that due to lack of supervision resident wandered away from facility. Between 10:45am and 11:15am, staff interviews were initiated. Interviews revealed that facility is not a locked facility. Residents are free to come and go as they please. Moreover, on 2/19/24, R1 left the facility and did not use the sign out book. After 24 hours had passed, the facility contacted the Glendale Police Department and filed a missing person's report. R1 returned to the facility on 3/04/24. Between 11:30pm and 12:00pm, LPA reviewed facility records. Records confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 31-AS-20240305113301

Allegation investigated: Facility is in disrepair

At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina, Perchui Milena Khurshudyan conducted an unannounced, joint visit with Investigator, Johnny Canto, at this facility to investigate the above allegation. The team met with the Administrator and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:10am, LPAs requested resident and staff roster. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Centrally Stored Medication and Distruction Record (CSMDR), Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:30am, the team conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:40am – 1:15pm, the team conducted an interview with the Administrator, Administrator Assistant, MedTech, two (2) staff, two (2) housekeepers, and five (5) residents out of six (6) residents. Continue on LIC9099-C Substantiated During the interviews, the team was able to visit four (4) random resident rooms and inspected/tested four bathroom sinks/faucets for the leaks. The team did not observe any faucets leaking. Interviews with five (5) out of six (6) residents revealed that they had no issues with the shower and or faucet leaks. However, in two (2) out of four (4) rooms, the team observed that the outlet wall plates were broken/missing. Administrator informed the team that the electrician was already contacted and the work will be completed today. Based on the inspection and observation, this allegation is Substantiated. Deficiency cited on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered. Allegation: Staff does not provide PRN medication to residents in a timely manner It was alleged that staff does not provide PRN medications to residents in a timely manner. To investigate this allegation, the team conducted an interview with the Administrator and the MedTech and was informed that all PRN medications are provided to residents in a timely manner and the staff immediately initials the PRN log. In addition, interviews with four (4) out of six (6) residents revealed that they never had any problems taking their medications or waiting for their medications for a long period of time. Lastly, the team conducted an inspection of R1's prescribed and PRN medications and did not observe R1 being prescribed a PRN (Ativan) medication. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time. Allegation: Staff refused to seek medical attention for resident. To investigate this allegation, the team conducted an interview with the Administrator and was informed that the facility staff always contacts 911 when an incident occurs with residents. Once the paramedics arrive and determine that it is not an emergency situation they may not take the resident to an Emergency Room (ER). In addition, the team was informed that the resident also has an option to refuse 911 services, upon paramedics arrival. Moreover, the team was informed that R1 calls 911 very frequently and most of the time the calls are done for a false emergency situation due to R1's medical and mental condition. Interview with two (2) staff members revealed that before their employment facility provided a training regarding the emergency situation and procedures. Both staff members also informed the team that each and every emergency situation is being handled, immediately. Interviews with four (4) residents revealed that the staff members are well trained and handle emergency situations on a professional level. Lastly, review of R1 Incident Reports confirmed that the facility always calls 911 when resident expresses behavior episodes and or upon residents' request. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time. Allegation: Staff does not keep the facility clean and sanitary To investigate this allegation, the team visited five (5) resident random rooms and observed all rooms are clean and well taken care of. The team also conducted an interview with two (2) housekeepers and was informed Continue on LIC9099-C that the facility resident rooms and common areas are being cleaned every day. Lastly, the team conducted interviews with five (5) residents and none of the residents expressed any issues/concerns regarding this allegation. Based on observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegations is Unsubstantiated at this time Allegation: Staff does not safeguard resident's personal items. It is alleged that R1's personal item has gone missing. During today's walk through, the team observed that the missing item that was initially reported missing was actually present at R1's room. In addition, interview with the Administrator revealed that at times residents may misplace their personal items and once it brought up to the management's attention the facility staff will relocate and return the missing item. Moreover, the team conducted interviews with five (5) residents and four (4) out of five (5) residents did not express any concerns regarding this allegation. Based on observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegations is Unsubstantiated at this time. Allegation: Staff is disrespectful to resident. It was alleged that facility staff members yell at the residents during the dinner time if they don't hurry finishing their meals on time (by 6:00pm). Interviews with the Administrator, two (2) staff members revealed that at times staff members might raise their voice to those residents that are hard of hearing. When they speak to those residents that are hard of hearing the raising of their voice is not meant to be in anger/disrespect, it is just so that the resident understands what the staff members are talking about. Moreover, interviews with four (4) out of six (6) residents confirmed that they are being treated very well by the facility staff members and were never treated disrespectfully by the staff. Based on information obtained through interviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 31-AS-20240122122023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 2, 2024

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the observation, licensee failed to ensure that the outlets in room #6 and room #22 had a wall plates, wich poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator already contacted the electrician to replace/fix the outlet today. Proof of picture shall be submitted to LPA by POC date.

Allegation investigated: Staff did not ensure menu was made available for review by the residents.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met wiith Administrator Peter Babaian and discuseed the reason for the visit. It was reported that staff did not ensure menu was made available for review by the residents in care. To investigate this allegation on 01/18/2024, between 12:30pm and 1:00pm, staff interviews were initiated.I nterviews revealed that the internet was down and that the printer was also out of ink . Internet service was out for about half a day on 01/14/2024. The ink for the printer was ordered thrink though Amazon. The ink took a while to be delivered and therefore an employee was sent to Staples to purchase the ink. Once the ink was available the menu was printed and posted. LPA also spoke to a kitchen staff member who confirmed what the Administrator had told LPA. Between 1:00pm and 1:15pm, LPA requested and reviewed menus. The menu for the week of 1/14/2024 was printed, posted, and availble for review. Continue on 9099C Unsubstantiated Based on observation, interviews, and records review, there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 31-AS-20240116090846

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA Valenzuela met with Administrator Peter Babaian and explained the purpose for the visit. The facility has an approved mitigation plan on file. The facility is a one-story building located in a residential area. It is licensed to serve (60) elderly residents, ages 60 and over, of which (49) may be non-ambulatory and (4) may be bedridden in rooms# 11 and #28 only. The property also has (2) cottages, #1511 & #1515 reserved for ambulatory residents only and has a hospice waiver approved for (6). The building consists of a living room, kitchen, dining room, 29 resident bedrooms with restrooms, common showers and bathrooms with required grab bars and non-skid mats, a laundry room/storage located in the basement, and a shaded patio in the backyard with seating. The cottages are located across the back yard and each have 4 bedrooms with a shared bathroom/shower, which had the required grab bars and non-skid mats. LPA observed resident bedrooms# 4, 7, 23, and 29 to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. Each room had a bathroom and were observed to have a toilet with the required grab bars and a wash basin. The water temperature was tested in the bathrooms of each room observed and in cottage# 1511, and measured between 111*F-119*F, which is in compliance with Title 22 Regulations. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. Several fire extinguishers were observed throughout the building and in the cottages to have current inspections and were fully charged. All sharps were observed to be locked and inaccessible in the kitchen. Cleaning supplies were locked and inaccessible, stored in cabinets in the basement and in a storage shed in the back yard. All laundry and kitchen equipment was operational and in good repair. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. Continue on 809C There is one central entry point. No bodies of water observed. There is one complete first aid kit. (5) random resident files were reviewed and had updated emergency contact information and health screenings. (3) random staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. At this time no health and safety noted. No citations will be issued. An exit interview was conducted with Administrator Peter Babaian and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 18, 2024

Allegation investigated: Staff did not notify resident of positive COVID test Staff did not provide resident with medical records upon request Staff did not quarantine resident

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff did not notify resident of a positive COVID test result. To investigate this allegation on 1/03/2024, between 2:00pm and 2:30pm, facility records were requested and reviewed. Records revealed that on 10/25/2023, Resident #1 (R1) was tested for COVID-19. The results came back ABNORMAL, but did not verify that they were COVID positive. On 11/01/2023, R1 was once again tested for COVID and the resutls stated that the virus was not detected. Between 2:30pm and 3:00pm, staff interviews were intitated. Interviews revealed that R1 was not COVID positive, but that their results were inconclusive. The facility did notify R1 of the results and told them to stay inside their room out of precaution. Based on interviews and records review, there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Unsubstantiated It was alleged that staff did not provide resident with medical records upon request. To investigate this allegation on 1/03/2024, between 2:30pm and 3:00pm, staff interviews were initiated. Interviews revealed that the facility does not store the medical records of R1. R1 needs to request medical records from their doctor. In addition, R1 was notified of the ABNORMAL Covid test results taken on 10/25/2023. According to staff, R1 was given a copy of their COVID test results in a timely manner. Based on interviews there is not sufficient information to verify this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. It was reported that staff did not quarantine resident. To investigate this allegation on 1/03/2024, between 2:30pm and 3:00pm, staff interviews were initiated. Interviews revealed that R1 was told to quarantine out of precaution, due to the fact that their test results were ABNORMAL for Covid-19 on 10/25/2023. Based on interviews, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 31-AS-20231228163838

Allegation investigated: Staff are not assisting residents with getting COVID vaccinations

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff are not assisting residents with getting COVID vaccinations. To investigate this allegation, on 1/03/2024, between 1:00pm and 1:15pm, staff interviews were initiated; Interviews revealed that all residents have been vaccinated for COVID. Between 1:15pm and 1:30pm, LPA requested and reviewed facility records. Records confirmed what staff had told LPA. Moreover facility records showed that Resident #1 (R1) received four COVID vaccines. Currently there are only four COVID vaccines available. The third and fourth vaccines are optional. Between 1:30pm and 2:00pm, resident interviews were conduted. Interviews revealed that they received the COVID vaccine. Based on interviews and records review there is sufficient information to not support the allegation. Thus, this allegation is UNSUBSTANTIATED at this time. EXit interview conducted and a copy of the report was issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 3, 2024 · control 31-AS-20231229095833

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to provide appropriate care and supervision to resident after the fall. Staff did not provide medical assistance to resident in a timely manner. Insufficient staff to meet the needs of the resident(s).

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on th above allegations that were investigated by DSS/CCLD Investigations Branch (IB) Investigator Laura Garcia. The purpose of the visit was explained to Administrator Peter Babaian. The investigation consisted of: On 5/12/2022, LPAs Galarza and Yating Yang conducted a 24-hour health and safety check that included a physical plant tour of the facility, and review of resident (R1's) file. The following documents were obtained: Identification and Emergency Information, Preplacement Appraisal, Resident Appraisals, Physician Reports, Psychiatric Evaluation/Notes, Medication Administration Record (MAR), Admission Agreement, Assisted Living Waiver/Individual Service Plan, incident reports [5/5/2022 & 10/18/2021], notes, resident roster, LIC 500 Personnel Report, and Death Report. A police report was not obtained during the initial visit. Investigations Branch obtained Glendale Fire department, Police records, County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report and Registrar- Certificate of Death. A nurse consult was obtained. ****Narrative continues next page.***** Substantiated Allegation: Staff failed to provide appropriate care and supervision to resident after the fall. It is alleged that on 5/5/2022, resident (R1) sustained 2 falls. The 1st fall occurred at approximately 7:30 PM while being provided incontinence care by caregiver (S1) in the facility common bathroom. The 2nd fall was unwitnessed and occurred in the resident's room at approximately 8:00 PM - 8:30 PM. While staff (S1) was changing R1’s diaper in the common bathroom the resident fell to the ground. The resident was unable to get up on their own or with S1’s help due to their size. Caregiver/Staff (S1) used the Hoyer Lift to pick the resident up from the floor, and then proceeded to walk the resident back to their room. Facility staff failed to use proper equipment and follow equipment use guidelines when assisting R1 with incontinence care that resulted in the first fall in the bathroom. Staff placed R1 in the bed and returned to check on the resident at approximately 8:00 PM – 8:30 PM. Staff (S1) found the resident face down on the ground beside the bed. Staff (S1) stated that they decided to place a pillow under the head, so the resident did not get hurt, since R1 was likely to fall again. Staff (S1) stated the resident only replied “okay". Based on interviews with staff on duty, staff 9S1) and CNA/staff (S2) did not provide appropriate care and supervision after both falls. Review of evidence indicates that staff (S1) placed resident in a harmful situation by placing a pillow under the head (partially covering the face) and left the resident on the floor. Emergency personnel observed the resident's bed did not have any bed rails. Proper safety measures were not in place. Allegation: Staff did not provide medical assistance to resident in a timely manner. It is alleged that facility caregiver (S1) and Certified Nurse Assistant (CNA)/Staff (S2) failed to provide timely medical attention by not rendering or initiating CPR when resident (R1) was not responsive. The facility failed to seek timely medical attention when R1 fell the 2nd time and was found on the floor. Emergency Medical Services (EMS) were not called almost two (2) hours after resident (R1's) 2nd fall, instead staff (S1) placed a pillow under the resident's head. Based on the photo, the resident was left on the floor in compromised position that appears to show R1 in prone position with left arm underneath body and right arm extended out in downward position. Caregiver staff (S1) reported both falls to CNA on duty. The 1st fall occurred at approximately 7:30 PM. The 2nd fall occurred at approximately 8:00 PM – 8:30 PM. At approximately, 9:30 PM, caregiver returned to the room to check on the resident because 2 other residents were heard screaming from R1's room. The resident was still laying on the ground with head on the pillow. Staff (S1) allegedly placed their index finger under the resident’s nose to see if any air was coming out from the nose. Staff (S1) stated the they felt air and left without providing further aid. According to staff interviews, staff (S1) reported the falls to Certified Nurse Assistant (CNA)/staff (S2). Sometime between 9:00 PM - 9:30 both staff went to check the resident. CNA stated that they stood by the door while staff (S1) checked on the resident and stated that staff (S1) reported the resident was okay. At 10:11 PM staff called EMS and reported to dispatcher that the resident was conscious. At 10:14 PM, EMS personnel arrived at the facility and found the resident "Dead on Arrival". Time of death was 10:17 PM. Paramedics determined the resident had been deceased longer six minutes. ***Narrative continues next page.**** Allegation: Insufficient staff to meet the needs of the resident(s). It is alleged that the facility did not have staff of adequate number and skill to provide care to the residents. When Emergency Medical Services (EMS) arrived staff delayed in allowing emergency responders crew into the facility. In addition, it is alleged that staff did not provide 911 emergency response dispatchers accurate information pertaining to resident's condition. Staff interviews revealed that during the afternoon shift staff (S1) is usually assigned to the front desk and when residents require immediate assistance it become very difficult to assist the residents. The findings indicate that on Saturdays and Sundays staff (S1) is the only person working from 2:00 PM - 10:00 PM; which includes providing the residents with meals, passing out medications, offering them snacks, and changing diapers for all the residents in need. In addition, the graveyard shift (10:00 PM - 6:00 AM sometimes has only one (1) staff working, and two hourly checks are not always performed. Staff interviewed acknowledged that due to staffing shortages, neglect and lack of supervision are likely. On May 5, 2022, both staff on duty (S1) and (S2) failed to provide medical assistance (CPR) or conduct a body assessment on resident (R1). On the resident (R1's) Appraisal/Needs and Services Plan dated 12/3/2020, it states the resident is at risk for falling, needs assistance with daily activities, and daily monitoring/observation will be performed. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22 and Health and Safety Code. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM. The issuance of a civil penalty is being considered based on Health & Safety Code HSC §1569.49(e) – (f), if the department determines the serious bodily injury was due to neglect. Exit interview was conducted with Peter Babaian. A copy of the report and appeal rights were provided. Allegation: Questionable Death. It is alleged that resident (R1) died at the facility due to neglect of care. On 5/5/2022, at approximately 8:00 PM - 8:30 PM caregiver staff (S1) found the resident laying in a prone position with face down but did not pick-up the resident, only placed a pillow under its head, and left the resident on the floor. Night shift staff placed a 911 emergency call until 10:11 pm. The decedent was found dead by emergency responders. Resident (R1) had bruising on their lower back that led further under the diaper, had a fresh cut on back, and had a visible dislocated left shoulder. A picture was taken, and appears to show R1 in prone position with his left arm underneath and right arm extended out in downward position. Left knee bent with left foot darker color extending pass their ankle. Based on County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report (5/8/2022) and Registrar- Certificate of Death records the cause of death is listed as "Natural". Other conditions contributing but not related to immediate cause of death listed Diabetes Mellitus and lymphoma. There is insufficient evidence to substantiate death as autopsy report ascribe cause of death to Arteriosclerotic Cardiovascular Disease and manner of death as natural. 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 Unsubstantiated. Exit interview was conducted with Peter Babaian. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 28-AS-20220510135636

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 13, 2023

Incidental Medical and Dental Care (a) ...The plan...shall provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange...for medical care... appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on documents reviewed and interviews conducted, facility staff failed to call Emergency Medical Services (EMS) personnel in a timely manner. Staff called 911 EMS approximately 2 hours after 2nd fall was discovered. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator shall submit in writing how this deficiency will be addressed, understanding of regulation, and facility procedures regarding timely medical care. 1.Submit plan by tomorrow. 2. Submit proof of staff training by Oct. 19,2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 13, 2023

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on document review and interviews conducted, on May 5, 2022 facility staff failed to meet the needs of resident (R1) after 2 fall incidents; by not conducting body assessments or providing adequate supervision subsequent to falls. This posed an immediate safety risk to this resident in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator agreed to (1.) submit a plan of correction that addresses staff scheduling and supervision of residents. When applicable resident’s care plans shall be updated, and staffing scheduling shall be reevaluated. (2.) Submit proof of staff training i.e., needs and services of residents, resident care, and supervision.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 19, 2023

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met evidenced by: Based on record review on May 5, 2022, R1 had 2 falls, (one in incontinence care room & the other in their room); staff did not provide appropriate care and supervision after both falls. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator agrees to conduct training with all staff regarding observation of residents and changes in condition. When changes in condition are observed residents shall be assessed and records and Appraisals Needs and Services plan shall be updated.

Allegation investigated: Staff did not prevent a resident from causing an injury to another resident Staff yell at the residents while in care Staff did not ensure a resident was taking prescribed medications Staff do not provide a comfortable temperature for the residents Staff speaks inappropriately towards a resident

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit for the above noted allegations. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff did not prevent a resident from causing an injury to another resident. Resident #1 (R1) accused another resident of purposefully backing into them and causing them to fall and get hurt. To investigate this allegation on 10/12/2023 between 10:50AM and 11:30AM, staff interviews were initiated. Interviews revealed that facility was not aware of Resident #1 (R1) being injured by another resident. It is possible that Resident #2 (R2) got too close to R1 and accidently bumped into them. Between 2:00PM and 2:20PM, LPA attempted to interview R1, but they were unable to identify who backed into them or when the incident occured. Based on interviews there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Unsubstantiated It was alleged that staff yell at the residents while in care. To investigate this allegation, LPA interviewed facility staff and residents. Staff interviews revealed that staff do not yell at residents. Some residents are hard of hearing and they need to raise their voice in order to be heard. Between 2:20PM and 2:55PM, ten percent of the residents were interviewed. Resident interviews revealed that staff do not yell at them and that they are nice. Based on interviews there is not sufficient information to verify this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. It was reported that staff did not ensure a resident was taking prescribed medications. To investigate this allegation, between 10:50AM and 11:30AM, staff interviews were conducted. Interviews revealed that R1 refuses to take this medication as prescribed by their doctor. Staff can not force R1 to take their medications since it is their personal right to refuse. Between 2:00PM and 2:20PM, LPA spoke to R1. R1 stated that they do not like taking too much medication and that sometimes they refuse it. Based on interviews there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was alleged that staff do not provide a comfortable temperature for the residents. To investigate this allegation between 10:50AM and 11:30AM, staff interviews were conducted. Interviews revealed that the air conditioning board burned about a month in a half ago and that it was immediately fixed. Only the right side of the facility was affected by this. The A/C not functioning was reported in the morning and the following day it was fixed. Between 3:00PM and 3:15PM, LPA conducted a facility walk through. The facility temperature measured on the thermometer was 77 degrees. LPA felt fresh air throughout the facility. The facility was not hot and staff told LPA that the AC is functioning once again. Based on interviews and observation there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was reported that staff speaks inappropriately towards a resident. To investigate this allegation staff interviews were conducted between 10:50AM and 11:30AM. Staff interviews reveal that staff are professional and respectful towards residents in care. Between 2:00PM and 2:20PM, LPA interviewed R1. Interview revealed that R1 was upset at staff because they thought someone stole their belongings. Staff were trying to calm them down and reassuring them that no one took their belongings. R1 denied that staff spoke to them inappropriately. Based on interviews there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 31-AS-20230829112003

Allegation investigated: Staff did not ensure facility is insect free

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Babaian and explained the reason for the visit. It was reported that staff did not ensure facility is insect free. On 10/12/2023 between 10:50AM and 11:30AM, staff interviews were initiated. Staff interviews revealed that when the administrator is present the entrance door and patio doors are left open. It is possible that flies enter the building. Between 11:30AM and 11:45AM, facility records were reviewed. Records revealed that a pest control company comes bi-monthly to the facility. Between 1:00PM and 1:30PM, LPA toured resident bedrooms. In room 14, LPA observed many flies. Some flies were alive and others were dead. Resident #1 (R1) was alseep at the time and was not able to be interviewed. Based on observation there is sufficient information to verify the allegation. Therefore, the allegation will be SUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued. Substantiatedthe state’s words, verbatim · CDSS document, Oct 12, 2023 · control 31-AS-20231004153247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 26, 2023

87303-Maintenance & Operation (a) The facility shall be clean, safe sanitary and in good repair at all times. Maintence shall include provision of maintence services and procedures for the safety and well-being of residents, employees, and visitors. This requirement was not met as evidenced by: LPA observed many flies in resident room #14. LPA observed both flies that were dead and alive. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: The licensee shall place fly strips in room #14 in order to deter flies. This citation has been cleared on this visit. Administrator placed the strips in room #14 during this visit..