Wellness Assisted Living

Type of visit: Office

Licensing Program Analyst (LPA) Mariana Agban and Licensing Program Manager (LPM)Mary Flores, conducted an Informal Meeting with Lusine Meliksetyan, Licensee/ Administrator today at the Woodland Hills Adult and Senior Care Regional office. The purpose of this Informal Meeting is to discuss existing deficiencies and current problem areas in the operation of the facility. On today's meeting the following was discussed: The informal Meeting process was explained to the Licensee/Administrator. The Administrator/Licensee was also informed that further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. On July 31, 26, Community Care Licensing (CCL) received a complaint which alleged "Staff are unable to communicate with residents. On August 10, 2025, LPA Agban conducted a complaint investigation in which the allegation was substantiated. It was explained the concerns regarding facility staff inability to communicate with the resident which it may be a potential health and safety concern. Plan of Correction (POC) that was implemented on August 10,2026. Licensee/Administrator had disclosed that facility current census is 6 with 2 staff member on each shift. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 1, 2026

Type of visit: Case Management - Deficiencies

In conjunction with the complaint 31-AS-20260731094111, LPA Mariana Agban conducted a Case Management Deficiencies visit to address the identified deficiency. During the course of the investigation, the Licensee/Administrator was unable to come to the facility. The Licensee/Administrator stated that there is currently no designee to act on the Licensee/Administrator's behalf. LPA advised the Licensee/Administrator to hire staff to act on the Administrator's behalf when the Administrator is not on the premises. Based on the information obtained, the facility is being cited pursuant to Title 22 regulations (see LIC 809D). An exit interview was conducted, and a citation was issued. Appeal rights were provided, and a copy of this report was reviewed with the Administrator.the state’s words, verbatim · CDSS document, Aug 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 17, 2026

When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement is not met as evidenced by: Based on interviews, Licensee/ Administrator does not have a designated substitute for managing the facility when the Licensee/Administrator is not on the premises. This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Aug 10, 2026

Plan of correction: Administrator/License agreed to complete LIC 308, naming a designee for the facility by the POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff#1 (S1) and explained the reason for the visit. LPA called Administrator LUSINE MELIKSETYAN who could not attend today's visit. Administrator Designee Ruzanna Manukyana came in her place arrived shortly after. At 09:15 AM LPA took a tour of the physical plant. Required postings were observed in the entry area. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the office cabinets. The fire extinguisher is located in the kitchen with a purchase date of 03/23/26. Smoke alarms and carbon monoxide were tested and are functional. Bedrooms: The facility has four (4) bedrooms of which two are shared room. All four (4) bedrooms were toured and appear to be clean and properly furnished. Bathrooms: There are two (2) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 109.3 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry room: was locked and inaccessible to residents. Garage: The garage was observed to be only used for storage. (Continue on 809 C) Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date. Last disaster was conducted on 01/14/26. LPA obtained copy of Emergency and disaster plan that was reviewed and updated on 01/10/26. Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed that medication records are not updated for the month of March of 2026. Exit interview conducted, citation issued, appeal rights given, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 23, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff#1 (S1) and explained the reason for the visit. Staff informed LPA that they were unable to understand English and went inside to wake up Staff#2 (S2). LPA observed S2 sleeping on the couch of the living room. LPA called Administrator LUSINE MELIKSETYAN who could not attend today's visit. Administrator Designee Ruzanna Manukyana arrived shortly after. At 09:30 AM LPA took a tour of the physical plant. Required postings were observed in the entry area. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the office cabinets. The fire extinguisher is located in the kitchen with a purchase date of 04/11/24. Smoke alarms and carbon monoxide were tested and are functional. Bedrooms: The facility has four (4) bedrooms of which one is a shared room. All four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed that staff are using resident closet in Room#2 to store clothes and other personal items. LPA asked S2 for the reason and S2 stated that there's no other place to store their personal items. Bathrooms: There are two (2) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 115.7 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry room: was locked and inaccessible to residents. Garage: The garage was observed to be only used for storage. (Continue on 809 C) Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms.Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date. LPA observed that S2 has incomplete LIC 501. Interview with S2 revealed that S2 has insufficient qualifications. LPA also interviewed S1, and S1 couldn't answer any of the LPA's questions due to the language barrier. Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed that medication records are inconsistent with medication audit. Exit interview conducted, citations issued, appeal rights given, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 5, 2025

Allegation investigated: Staff are unable to effectively communicate with a resident in care. Staff did not meet the minimum qualifications to provide direct service to resident(s) Staff did not seek medical attention in a timely manner.

Licesing Program Analyst (LPA) Mariana Agban arrived at the above facility to conduct intitial complaint visit. Upon entrace LPA was greeted by Staff #1 (S1). Adminstator was contacted and the reason for the visit was explained. LPA was informed that the Administor wasn't able to come to the facility and designated Staff 3 (S3) to sign for the report. LPA requested copies of LIC 500 and Resident Roster. LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Allegation: Staff are unable to effectively communicate with a resident in care. It was alleged that the facility staff was unable to communicate with emergency responders due to language barrier. Interview with S3 confirmed that staff has a communication barrier, however, staff can meet residents' basic needs. S3 stated that on 10/18/24 staff had reported to the Administrator that Resident 1 (R1) was unresponsive and Administrator had called the paramedics. On today's visit, LPA attempted to interview Staff 1(S1) and Staff 2 (S2) but they stated that they don't understand very well English (Continue on 9099C) Substantiated S1 had asked LPA to use a translation service through S1's phone to translate questions into Russian. LPA attempted interview five out of five residents. Based on information obtained the allegation is deemed Substantiated at this time. Allegation: Staff did not meet the minimum qualifications to provide direct service to resident(s) It was alleged that staff didn't know R1's medical history, normal mental status, POA, or resuscitation wishes. Administrator denied the allegation. LPA conducted file review and observed that S1 and S2 didn't meet the minimum qualifications to provide direct services to residents. There were no indications of S2 in-service training. S2 was unable to tell residents names and had to ask S1. Although S1 had in-service training, S1 was unknowledgeable to provide any medical information regarding R1 and other residents. Interview with Administrator revealed that S1 and S2 had no previous related experience to the job as caregivers. Based on information obtained the allegation is deemed Substantiated at this time. Allegation: Staff did not seek medical attention in a timely manner It was alleged that staff did not seek medical attention in a timely manner. Administrator denied the allegation. Administrator stated that staff had reported that R1 was unresponsive and thus 911 was called by the Administrator. Moreover, Administrator stated that R1 had been unresponsive a couple of times since their admission to the facility. Interview with Administrator revealed that they are not fully aware of R1's medical condition. Based on information obtained the allegation is deemed Substantiated at this time. Exit interview conducted, citations issued, appeal rights given copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 31-AS-20241029134703

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Nov 28, 2024

87411-Personnel Requirements - General-(d)(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.,.This requirement is not met as evidenced by: Based on interviwes staff was unable to communicate with LPA, Staff was using translation device. This poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Nov 28, 2024

87411-Personnel Requirements - General-(d)(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help Based on interviwes staff were unable to recoginze ealrly signs of illness which led R1 to hospitalization.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Administrator will conducted training to address this section of the regulation. Attendace sheet will submitted to the LPA by the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 8, 2024

Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement has not been met as evidenced by The licensee failed to ensure staff provided adequate observation regarding R1’s change in condition, and adequate records pertaining to R1’s health and care which led to R1’s hospitalization. This poses as an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Licensee will submit a written plan stating how the facility will ensure that all residents in care are provided with adequate care and supervision to ensure their safety and their needs are being met. Plan to be submitted to CCL by the POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d) · Plan of correction due date: Nov 28, 2024

87411-Personnel Requirements (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This requirement has not been met as evidenced by: Based on records review S2 doesn't have in service training. This poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Administrator will conduct training for S2 and submit attendance sheet by the POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Staff informed LPA that they were unable to understand English and called Administrator LUSINE MELIKSETYAN who could not attend today's visit. Administrator Designee Ruzanna Manukyana arrived shortly after. At 10:10 AM LPA took a tour of the physical plant. Required postings were observed in the entry area. LPA observed dining room ceiling had water stains and cracks in the ceiling. Staff had an empty packet in the middle of the floor to gather the water dripping off the roof. LPA asked the Administrator Designee regarding the roof leaking and when it happened. Administrator Designee stated that the leak happened last week due to the rain. Administrator Designee stated that the property owner will fix the roof when the rain stops. LPA advised the Administrator Designee that this poses a potential health and safety to residents in care. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the office cabinets. The fire extinguisher is located in the kitchen with a purchase date of 7/11/23. Smoke alarms and carbon monoxide were tested and are functional. Bedrooms: The facility has four (4) bedrooms of which one is a shared room. All four (4) bedrooms were toured and appear to be clean and properly furnished. Bathrooms: There are two (2) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 113.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry room: was locked and inaccessible to residents. Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date. LPA observed that S1 and S2 are not on the training list for February Administrator Designee stated that they have taken training's but their names were not on the list. LPA also observed that S1 and S2 had not signed any of the training's that the Administrator Designee stated they took. In addition, LPA oberved there's no physical file of Administrator Designee. Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed that R1's centrally stored medication and destruction record is missing all information regarding the medication name and start date. R2's centrally stored medication and destruction record is missing the start date. R3 Buprenorphine Medication was missing doses for March 11,12,13, and 14. The Buprenorphine medication is instructed to take one tablet daily. LPA was informed that the staff had a doctor's order to give this medication twice a day instead of once. LPA requested to see medication instructions change but staff couldn't provide them. LPA also observed that Quetiapine is missing 56 tablets. Exit Interview Conducted, citations issued, copy of the report delivered and appeal rights given.the state’s words, verbatim · CDSS document, Mar 7, 2024