Ymz Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Gulshair Iusupova, Staff. Staff contacted the Administrator via telephone and she arrived at 11:16am to conduct the visit. The reason for today's visit was provided. The facility is a single storey home consisting of a living room, dining room, kitchen, 3 bedrooms and 2 full bathrooms and a fenced in swimming pool. Located in the back of property is a separate 2 storey ADU. The facility has a fire clearance for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #1 is the approved room for bedridden use. On today's visit, all 12 domains of the CARE Inspection Tool was reviewed. LPA Yee also reviewed 6 resident and 8 staff files and conducted a tour together with the Administrator of the entire facility, inside and outside, on today's visit. The living room, dining room and kitchen had the appropriate furnishings and equipment for its designated use. The fireplace was covered with a fire screen and made inaccessible to the residents in care. Located inside the kitchen are the 2 fire extinguishers purchased on 3/15/26. Sharp knives are stored in a locked kitchen drawer, to the right of the stove. Sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed in the kitchen refrigerator, kitchen cabinets and the 2 refrigerators located in the covered patio located in the back. Drinking water was stored in the shed located by the swimming pool. The three resident bedrooms are shared rooms furnished with 2 hospital beds, 2 chairs, 2 night stands, continued on LIC809-C Page 2. 2 lamps, 2 dressers in bedroom #1 and a single dresser in the remaining room and a built in closet. The facility has 2 full bathrooms, of which one is a private bathroom located inside bedroom #2. The private bathroom is equipped with a toilet, a sink, a large tub and a walk in shower. Grab bars and a slip resistant mat was observed. The common bathroom is equipped with a sink, a toilet and a bathtub with a shower. Grab bars and a slip resistant mat was observed. The water temperature tested in the private bathroom read 112.6 degrees and the water in the common bathroom read 115.5 degrees Fahrenheit. The resident hallway does not have outlets for night lights. The hallway has a light fixture that is left on for lighting. The residents beds were observed with mattress covers, fitted sheets, a blanket, some with flat sheets as per request of the residents. Extra linens were observed in the hall way closet. The hardwired smoke/carbon monoxide detectors located in the resident hallway, dining room and living room and smoke detectors in the resident bedrooms were tested and were operational. The fire rated door was operational. The cleaning solutions are stored in a locked cabinet under the kitchen sink and in a locked cabinet in the laundry room. Medications are stored in a locked metal cabinet located in the dining room. The facility has current general liability insurance with limits of $1 million per occurrence and $3 million total annual aggregate. The first aid kit was reviewed and contained the required tweezer, scissors, dressings and a external thermometer. A first aid manual was observed. The auditory devices located on four outside exiting doors - kitchen, bedroom #1, bedroom #2 and the front door were operational. located in the back of the facility is a covered patio with a coffee table and chairs and 2 refrigerators. located on the other side of the rod iron fence are 2 storage sheds. The trash cans were observed located in the front. Overall, the inside and outside of the facility were observed to be clean. No deficiencies were cited on today's visit Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2026

Allegation investigated: . Staff hit resident in care

Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to deliver the findings of the investigation based on the information received during the interviews and documents that were previously provided and was let into the home by Gulshair Iusupova, Staff. Rebeka Durgaryan, Administrator was contacted by staff but she did not The reason for today’s visit was provided. On 9/6/24, Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced 10-day complaint investigation visit to the facility above. The LPA met with facility staff member Ada Bozkurt, at 03:42 PM and explained the purpose of the visit. Facility staff contacted the facility administrator Rebeka Durgaryan who arrived at the facility at 04:20 PM. Entrance interview conducted and the reason for the visit was explained. continued on LIC9099-C Unsubstantiated Page 2 On 9/6/24, Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced 10-day complaint investigation visit to the facility above. The LPA met with facility staff member Ada Bozkurt, at 03:42 PM and explained the purpose of the visit. Facility staff contacted the facility administrator Rebeka Durgaryan who arrived at the facility at 04:20 PM. Entrance interview conducted and the reason for the visit was explained. During the 9/6/24 visit, starting at 04:23 PM, the LPA conducted a physical plant tour. The LPA also conducted interviews with residents, staff, and administrator between 4:29 PM and 4:40 PM and obtained copies of pertinent facility records. At this time, further investigation is needed. An LPA will follow up at a later date to continue the investigation. Exit interview conducted and a copy of the report printed. On 10/28/25, Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to continue the investigation for the above allegation and erroneously indicated in the report generated that she was there to deliver the findings of the investigation conducted entirely by Veronica Padilla, Investigator with the Investigation Bureau. LPA Yee was let into the home by Shazada Zholdoshova, Staff. Staff contacted the Administrator to advise of LPA Yee's visit. Per telephone contact with the Administrator at 1:36pm, she advised LPA that she was sick and could not conduct the visit. LPA met with Hasmik Baklajyan, Designated Staff. The reason for today’s visit was provided. On the visit conducted on 10/28/25, LPA Yee conducted a telephone interview with the Administrator to clarify the information previously provided as the staff could not locate Resident #1's file for review. Per the Administrator, she will email LPA Yee the documents later today. Due to time constraints and the lack of records, it has been determined that further investigation is needed before a finding could be made for the above allegation. Exit interview was conducted and a copy of this report was provided. The documents requested on 10/28/25 were emailed to LPA Yee by Rebeka Durgaryan, Administrator, during today’s visit. Per information received to date, regarding the allegation that Staff hit resident in care, the investigation revealed from interview conducted with Rebeka Durgaryan, she vehemently denies that any continued on LIC9099-C Page 3 of her staff hit residents. Per information provided by interview conducted with witnesses, the family were told that the swelling on the right side of the resident’s face was that Resident #1, fell out of their wheelchair and hit the wall on 8/24/24. Allegedly the fall was witnessed by an unknown staff. Per the Administrator, there were no witnesses to any falls because there were no falls. Per the second interview conducted with the Administer on 10/28/25, she indicated that this incident happened a year ago and does not remember what happened but stated that Resident #1 did not fall. She did state that Resident #1 was highly anxious and very aggressive, had mental issues and per the family, the resident had been abused by their spouse, based on the resident’s fearful reaction to staff and everyone at the facility. Per the Administrator, Resident #1 would hit their hand on the arm of the wheelchair and would hit the bed rail with their hand and head. Per the Administrator, the resident messed up the facility. Per the Administrator, on morning of 8/24/24, she was informed by Staff #1 that Resident was observed with a small bruise on the lower lip. Resident #1, diagnosed with dementia, could not explain how the bruise was sustained. On 8/29/24, Resident #1 was sent to the hospitalized for high blood pressure. Per the Administrator, she was present at the facility, and she was the one who called 911. Per the Administrator, Resident #1, was not observed with bruising, swelling or any injury to the face on the day of the hospitalization. Resident #1 was only observed with a little blue bruise on the lower lip on 8/24/24. The resident had a history of high blood pressure and was discharged from the hospital to the facility on 8/20/24, without any medications. Per the Administrator, the bruise was caused by the resident’s behavior. Per interviews conducted with staff, they indicated that they do not hit residents and do not have any issues with them. Per interviews conducted with residents, they all stated that the staff take good care of them and treat them fine. The residents also state that they have not seen any staff abuse any residents. During the investigation, LPA Yee was not able to identify anyone at the facility that could confirm that Resident #1 was hit by a staff member to sustain the facial swelling or the bruise to the lip. Per information provided by the continued on LIC9099-C Page 4 Reporting Party, the resident’s facial injuries were also checked by emergency room personnel during the visit on 8/29/24 for high blood pressure. Emergency room personnel could not conclusively state that the injury was the result of an assault or a fall or how the swelling was caused. Due to the lack of witnesses to the incident, there is insufficient evidence to support the allegation that staff hit a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur Exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 29-AS-20240830140921

Allegation investigated: . Staff caused an injury to a resident while in care

Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to deliver the findings of the investigation conducted entirely by Veronica Padilla, Investigator with the Investigation Bureau. LPA Yee was let into the home by Shazada Zholdoshova, Staff. Staff contacted the Administrator to advise of LPA Yee's visit. Per telephone contact with the Administrator at 1:36pm, she advised LPA that she was sick and could not conduct the visit. LPA met with Hasmik Baklajyan, Designated Staff. The reason for today’s visit was provided. On 2/25/25, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to collect facility documents related to the complaint and also included a health and safety visit to ensure that there were no immediate concerns with the physical plant and residents. LPA Yee was let continued on LIC9099-C Unsubstantiated Page 3. side. Staff #1 then pulled the resident towards them and placed part of the diaper beneath the resident. Resident #1 then had to roll over to their left side to allow staff to pull the diaper through to the other side. This was normal practice when Resident #1 was changed. On 2/16/25, Resident #1 rolled over to the left and misjudged the size of the bed and ended up on the edge of the hospital bed. Resident #1 continued to slip off the bed before Staff #1 could prevent the fall. Resident #1 landed on their left side. As a result of the fall, Resident #1 had left side pain, arm pain, bruising and swelling and lay on the floor for about 30 minutes before staff were able to transfer the resident back to bed. The acute displaced fracture of the distal humeral shaft injury was not known until 2 days later. Per the investigation conducted by Investigator Padilla, there was insufficient evidence to support the allegation that due to neglect, lack of supervision, staff caused an injury to a resident. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided Page 2. into the home by Jossent Mckie, Staff. Rebeka Durgaryan, Administrator, was contacted via telephone by Ada Bozkurt, Staff and she arrived to conduct the visit at 11:59am. During the initial visit conducted on 2/25/25, LPA Yee conducted a tour of the facility and the resident rooms to observe the residents in care beginning at 11:14am, reviewed the food supply at 11:44am and did file review of all 5 resident files beginning at 11:50am. No formal interviews were conducted with staff or residents during the visit. Per tour of the facility on 2/25/25, no visually obvious concerns were observed with the facility. All 5 Residents were observed in their beds, either watching television, on a Zoom call for bible study and one resident in bedroom #3 was sleeping. Resident #1 was observed in bed wearing a hard splint on their entire left arm. Utilities were observed to be in use at the time of this visit. Food supply was inspected and there were sufficient perishable foods for a minimum of two days and non-perishable foods for a minimum of 7 days on site. There were 2 staff working during the visit. File review was conducted, and copies of resident files were requested. During the investigation conducted by Veronica Padilla, Investigator with Community Care Licensing Division’s Investigation Branch, she conducted interviews on 3/13/25 with Resident #1, Resident #2, Resident #3 and Resident #4. On 3/18/25, an interview was conducted with the Reporting Party. On 6/26/25 an interview was conducted with Staff #1, an interview with the Administrator and staff #2 on 7/1/25. Attempts to interview Staff #3 were unsuccessful. Also, as part of the investigation, facility files and documents such as medical records, hospice records and other extensive documents relevant to this complaint were obtained and reviewed. Regarding the allegation that staff caused an injury to a resident while in care, Resident #1, who is bed bound, was receiving incontinence care around 1745 hours(5:45pm) or 6:30pm on 2/16/25. Per interview with Staff #1 on the day of the fall, they started the diaper change while Resident #1 was laying on their right continued on LIC9099-C Page 2A ensure that there were no immediate concerns with the physical plant and residents. LPA Yee was let into the home by Jossent Mckie, Staff. Rebeka Durgaryan, Administrator, was contacted via telephone by Ada Bozkurt, Staff and she arrived to conduct the visit at 11:59am. During the initial visit conducted on 2/25/25, LPA Yee conducted a tour of the facility and the resident rooms to observe the residents in care beginning at 11:14am, reviewed the food supply at 11:44am and did file review of all 5 resident files beginning at 11:50am. No formal interviews were conducted with staff or residents on today's visit. Per tour of the facility on 2/25/25, no visually obvious concerns were observed with the facility. All 5 Residents were observed in their beds, either watching television, on a Zoom call for bible study and one resident in bedroom #3 was sleeping. Resident #1 was observed in bed wearing a hard splint on their entire left arm. Utilities were observed to be in use at the time of this visit. Food supply was inspected and there were sufficient perishable foods for a minimum of two days and non-perishable foods for a minimum of 7 days on site. There were 2 staff working during the visit. File review was conducted, and copies of resident files were requested. During the investigation conducted by Veronica Padilla, Investigator with Community Care Licensing Division’s Investigation Branch, she conducted interviews on 3/13/25 with Resident #1, Resident #2, Resident #3 and Resident #4. On 3/18/25, an interview was conducted with the Reporting Party. On 6/26/25 an interview was conducted with Staff #1, an interview with the Administrator and staff #2 on 7/1/25. Attempts to interview Staff #3 were unsuccessful. Also, as part of the investigation, facility files and documents such as medical records, hospice records and other extensive documents relevant to this complaint were obtained and reviewed. Regarding allegation #2 that Staff did not seek timely medical attention for resident, the investigation revealed that Resident #1 was receiving incontinent care on 2/16/25, around 1745 hours (5:45pm) or 6:30pm and had rolled over from their right side to their left side. Resident #1 misjudged the bed and had slipped onto the floor from the hospital bed. Resident #1 landed on their left side. Resident #1 experienced continued on LIC9099-C Page 3A. pain in the upper extremities and upper left arm with minimal movement. Swelling and bruising were noted on the forearm and elbow. Neither the Administrator nor staff called 9-1-1 to have the resident checked evaluated for any injuries. The resident was transferred back to bed after they spent about 30 minutes on the floor. Per interviews, staff stated that the resident refused medical services, despite the pain. Resident #1 receives hospice services for heart issues, and the Administrator called the hospice nurse on 2/17/25 to assess Resident #1 for the fall, despite the fall being unrelated to the resident’s hospice care plan. The hospice nurse suspected a fracture and scheduled an x-ray for 2/18/25. Upon evaluation, the nurse recommended that 9-1-1 be called, but the resident refused. The x-ray results revealed an acute displaced fracture of the distal humeral shaft. Again, the staff did not call 9-1-1 to obtain medical attention for Resident #1. Later that day, the resident had an in-person visit from the hospice doctor to discuss the results of the x-rays and treatment options were discussed. Hospitalization was recommended again and was refused by Resident #1. The potential consequences of the fracture was explained by the doctor and the resident still wanted to remain at the facility. On 2/21/25, almost a week after the fall, Resident #1 finally asked the administrator to be taken to the hospital. 9-1-1 was called to transport Resident #1 to the hospital. Per Investigator Padilla’s investigation, although the resident refused medical services, the resident signed an LIC627C – Consent for Emergency Medical Treatment Adult and Elderly Residential Facility, which was observed in the resident’s file. The Administrator should have exercised the authority granted to provide any necessary emergency medical care, regardless of the circumstances, to protect the resident’s wellbeing, but failed to do so. Resident #1 endured a total of 5 days of pain. Per the investigation, there is sufficient evidence to support the allegation that the staff did not seek timely medical attention for a resident, therefore the allegation is substantiated. Deficiencies are cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, Appeals Rights discussed and a copy was provided.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 29-AS-20250224100345

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Oct 29, 2025

Incidental Medical and Dental Care :The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Resident #1 slipped and fell from their bed and sustained a humeral fracture to the left arm, bruising and swelling to the forearm and elbow on 2/16/25 and 911 was not called to assess the resident and transported to the hospital until 2/21/25, 5 days after the fall.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: The licensee will provide the Department with a written plan of action that will be implemented to ensure that all residents get timely medical attention when a resident refuses to seek medical attention that threatens their life, limb and overall wellbeing by 10/29/25.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies noted on today's visit and during complaint visits conducted by Investigator Veronica Padilla related to complaint #29-AS-20250224100345. LPA Yee was let into the home by Shazada Aknmobha, Staff. Per information provided, she was working part time to cover another staff. The Administrator, Rebeka Durgaryan was contacted and staff indicated that she was on the way to conduct the visit. At 1:36pm, LPA Yee received a telephone call from the Administrator advising that she was sick and would not be participating in today's visit. Hasmik Baklajyan was going to conduct the visit. Ms. Baklajyan arrived at 2:10pm to conduct the visit. The reason for this visit was explained. The following deficiencies were noted: During the investigation conducted by Veronica Padilla investigator, information was provided that Svetlana Petrosian, staff that works for the licensee at North Care Residential Inc was present at the facility after the fall of Resident #1 on 2/16/25. Per review of Department records, staff was cleared on 4/24/15 and a request for a criminal record transfer to the facility was not processed until 6/19/25. Staff, Shazada Aknmobha, AKA as Sasha, was the only staff present at the facility upon LPA's arrival today. Per Sasha via translation app, she is working part time and is covering for Staff #2. Per review of the Department records, she does not have a criminal record clearance and is not associated to the home. Hospice Initiation and Notifications have not been provided to the Department for residents noted on the continued on LIC809-C Page 2. citation issued on 8/28/24 but not corrected and Resident #1. Per the Administrator, Resident #1 has since been discharged from hospice. Currently there is no one on hospice. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. CIVIL PENALTIES WERE ASSESSED ON TODAY'S VISIT Exit interview was conducted, APPEAL RIGHTS were discussed and a copy was provided.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2)) · Plan of correction due date: Oct 29, 2025

Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 2) Obtain a California clearance or a criminal record exemption as required by the Department or...This requirement was not met as evidenced by: Shazada A. Zholdoshova, Staff does not have an employee file and no evidence of a criminal record clearance. Per staff, it is her first day covering for Staff #2. Civil penalties were assessed.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: The Licensee shall read Title 22, Section 87355 and write a statement that the section was read and understood and a written plan of action is provided that will state how the facility will ensure that all staff present at the facility has received a criminal record clearance and requested a criminal record transfer by 10/29/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(3) · Plan of correction due date: Oct 29, 2025

Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requiement was not met as evidenced by: Svetlana Petrosian, an employee of the licensee at North Care Residential, Inc was observed at the home as staff from the licensees other facilities are used as backup staff and was not associated to the homethe state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: The Licensee shall read Title 22, Section 87355 and write a statement that the section was read and understood and a written plan of action is provided that will state how the facility will ensure that all staff present at the facility has received a criminal record clearance and requested a criminal record transfer by 10/29/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Nov 4, 2025

Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements. The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...... R1 through R4 are on hospice and was not reportedthe state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee will read Title 22 Section 87632 and 87633 and submit a written statement that the sections were read and understood and that the Licensee will comply with all requirements noted in the Section. Licensee will also submit written hospice notification letters containing all the required information noted in the Section being cited for resident #1 through resident #4 to the Department by 11/4/25

Allegation investigated: . Staff neglect resulted in R1's death 2. Staff did not seek timely medical attention for a resident 4. Staff did not meet R1's care needs 5. Staff is unable to communicate effectively 6. Staff is not properly trained and unqualified to care for residents 8. Staff did not have planned activities for the residents 9. Staff made unauthorized medical decisions for the residents 11. Staff mishandled a resident

Licensing Program Analyst (LPA) Christine Yee conducted another subsequent complaint visit to deliver the findings of the investigation for the above allegations. LPA Yee was let into the home by Crystal McKie, Staff. Rebeka Durgaryan, Administrator, was contacted by LPA at 10:05am, to advise her of today's visit and was informed that she was on a mini vacation and Naira Aghajanyan, Designated Staff,would conduct today's visit and she arrived at 10:34am to conduct the visit. The reason for today’s visit was provided. On 8/28/24, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above eleven allegations and also to conduct a 24 hour health and safety check. LPA Yee was let into the home by Ada Bozkrurt, Staff. Staff contacted Rebeka Durgaryan, Administrator via telephone and she arrived at 1:06pm to conduct the visit. This complaint was also referred to the continued on LIC9099-C Unsubstantiated Page 2 Investigation Bureau for investigation consideration on 8/28/24. The reason for today's visit was provided. On the visit conducted on 8/28/24, LPA Yee obtained information regarding Resident's date of admission, Resident #1's length of stay at the home, services that Resident #1 was being provided during the residents stay, reason for the hospitalization and the cause of death. A copy of Resident #1's faciity files, including list of medications, MAR logs and hospice documents were requested but was not able to be provided since the copier was out of order. Per Administrator, all the requested documents will be scanned to LPA Yee by the end of today. On 8/28/24, a tour of the facility was also conducted at 2:54pm to observe the residents and to ensure that the utilities were available, review the food supply and to observe any visually obvious deficiencies. Per tour of the facility, LPA Yee observed all the residents in bed napping or watching television, sufficient perishable and non-perishable foods were observed and additional food supply is being brought in today per staff, utilities, including the air conditioner were observed to be in use. Water temperature was tested in the common and private bathroom. Water temperature tested in the common bathroom read 119.7 degrees Fahrenheit and the water temperature in the private bathroom read 119.7 degrees Fahrenheit. The swimming pool was observed to be secured by a 5 feet fence and was locked. Visually there were no immediate safety concerns observed during today's visit. Based on the 8/28/24 visit, further investigation is needed to make a finding for all of the 11 allegations currently noted as personal rights. Exit interview was conducted with Ada Bozkurt, Staff since the Administrator had to leave at 2:16pm due to child care needs. On 7/23/25, Licensing Program Analysts (LPAs) Christine Yee and Quoc Huynh conducted a subsequent joint complaint visit to investigate the above allegations and was let into the home by Crystal McKie, Staff. Staff contacted Rebeka Durgaryan, Administrator via telephone to advise of LPAs' visit and she arrived at 9:34am to conduct the visit. The reason for today's visit was provided. On today's visit, LPA Yee conducted interviews with the Administrator at 10:14am, Resident #4 at 1:40pm and Resident #6 at 2:56pm. LPA Huynh conducted interviews with Resident #3 at 2:07pm, Resident #2 at 2:13pm and conducted file reviews at 9:56am and reviewed medications at 2:21pm in conjunction with a required annual inspection. Based on the information received from interviews conducted, files and medications reviewed, it was determined that continued on 9099-C Page 3 further investigation is needed to make a finding for the above 11 Personal Rights allegations. Copies of MAR Logs, Physician Report at time of Admission, Evidence of staff training by hospice agency will be sent to LPA Yee by close of business on 7/24/25. Exit interview was conducted and a copy of the report was provided. On 7/24/25, LPA Christine Yee and Quoc Huynh conducted another joint subsequent complaint visit to continue further investigation of the above allegations and another interview with the Administrator, was conducted at 10:34am to obtain additional information regarding the hospice services, medications and assistance with meals. Also collected on today's visit were documents requested on the 7/23/25 visit. Training logs were requested for Staff #3 and Staff #4 during the interview and will be provided by 7/25/25. On 7/23/25, LPA Huynh conducted interviews with Staff #1 at 1:50pm and Staff #2 was at 1:41pm by LPA Huynh and was not noted on the report generated for that visit. Based on 7/24/25 visit it was determined that further investigation is still needed to make a finding for the above allegation. An Exit interview was conducted with Svetlana Petrosian, Staff since the Administrator had to leave to pick up supplies. On today's visit, LPA Yee delivered the complaint findings of the investigation for all eleven (11) allegations.. Per interviews conducted and review of all documents collected, the investigation revealed that Resident # 1 was formerly living in a nursing home in Richfield, Utah and was being moved to California to reside at this facility. Per review of documents from the nursing home, Resident #1 had multiple comorbidities such as congestive heart failure, cirrhosis of the liver, chronic kidney disease, major depressive disorder, chronic respiratory failure with hypoxia, Type 2 diabetes mellitus with diabetic chronic kidney disease, chronic pain syndrome, hypertension, was weak, use of a pacemaker, just to name a few. Resident #1 moved into this facility on 3/31/24 and hospice services with Elara Hospice, Inc were initiated on 4/12/24 based on Resident #1’s primary diagnosis of chronic congestive respiratory failure with hypoxia and secondary diagnosis of chronic combined systolic and diastolic heart failure. Many complaints were received that Elara Hospice was not providing Resident #1 with services due to lack of hospice staffing, family wanted to know if the doctor continued on LIC9099-C Page 4 and the hospice nurse was checking on the resident, due to the resident’s decline, the oxygen concentrator was not working, and the resident couldn’t breathe and mostly, the hospice agency’s failure to respond to the family’s concerns were received while Resident #1 was under Elara Hospice’s care. The complaint also alleges that the licensee of this facility, also owns Elara Hospice. The licensee denied owning the hospice company. The Statement of Information filed with Secretary of State also confirmed that the licensee is not the owner. The family were unhappy with the services provided by Elara Hospice, so a decision was made to transfer Resident #1’s hospice services to a hospice agency used by a friend according to the Administrator. A final comprehensive assessment report was generated by Elara Hospice in preparation for the transfer of care to Liem Hospice, was conducted. Hospice services with Liem Hospice were initiated on 6/15/24. With the transfer of hospice services, complaints continued. Per the investigation, related to Allegation #1 - Staff neglect resulted in R1's death, the investigation revealed that Resident #1, who was 82 years was admitted to the facility on 3/31/24 from a nursing home located in Utah with multiple comorbidities that were terminal and was actively declining. Comfort services were being provided at the nursing home. On 4/5/24, five days after the resident is admitted, the family texts the Administrator and told her that Resident #1 had declined drastically this week and attributes it to neglect by staff. Resident #1 was actively declining, physically and mentally and the reason why Resident #1 was placed on hospice for comfort care and safety. Resident #1 continued to decline, even with the best of care. Per interviews conducted with the Administrator and facility staff, they do not neglect any residents. The residents interviewed also confirm that the staff are great and that they are not neglected. One resident even indicated that Resident #1 was unreasonable and required a lot of attention. Per review of the Certificate of Death, the cause of death is noted as acute respiratory failure and congestive heart failure with no mention of neglect. Based on the information obtained during the investigation, there is insufficient evidence to support the allegation that staff neglect resulted in R1’s death. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. The investigation into Allegation #2 - Staff did not seek timely medical attention for a resident. Per the continued on LIC9099-C Page 5 investigation, Resident #1 was admitted to the facility on 3/31/24. Resident’s #1’s hospice care did not begin until 4/12/24. On 4/5/24, only 5 days after arriving at the facility, the family texted the Administrator to inform her that the Resident may have pneumonia and may have a bladder infection and to let the nurse know. The Administrator responded back that the nurse was going to be at the facility that day and that they would order antibiotics. During the investigation, LPA Yee was not able to determine conclusively if the onset of the pneumonia or bladder infection occurred at the facility or at the nursing home to say the facility staff neglected the Resident, which resulted in the resident to develop pneumonia or have a bladder infection in the 4 days that they lived at the facility. Resident #1 has a history of bladder infections. On 4/9/24, the resident’s family were visiting, and they observed that Resident #1 was having difficulty breathing and took the resident’s pulse. They informed the Administrator and 911 was immediately contacted. Resident #1 was hospitalized on 4/9/24 and returned to the facility on 4/12/24. Per the investigation, staff would not have immediately observed the resident having shortness of breath while the family was visiting. Resident #1 was also diagnosed with chronic respiratory failure with hypoxia. The shortness of breath may have just been triggered during the family visit. Staff are not stationed at the residents’ bedside or hover around the residents and intrude on family visits. Based on the interview conducted, there is insufficient evidence to support the allegation that staff did not seek timely medical attention for a resident. Staff called 911 as soon as they were made aware. The call for emergency services for Resident #1 was also complicated by the fact that resident had on file a do not resuscitate order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is unsubstantiated at this time. The investigation into Allegation # 4 - Staff did not meet R1's care needs, it is alleged that the staff were not meeting Resident #1’s incontinence needs by leaving Resident #1 in their dirty pull ups, over medicating the resident, not properly feeding the resident while eating, not meeting their oxygen needs, not keeping the resident's vitals, addressing their glucose levels, high blood pressure and that unqualified staff are providing care and supervision. Per interviews conducted with staff and residents, staff state that they do not leave residents in their dirty pull ups and residents all confirm that staff change them immediately. Staff also state continued on LIC9099-C Page 6 that they do not over medicate the residents. Resident #1 brought their own medications when they first moved in. Staff dispense the medication as it was prescribed. Resident #1 is always in pain and takes many pain medications due to shortness of breath and pain. Resident #1 is always asking for more pain pills even after they take their routine pain medications. Per the Administrator, she tells the family about it. Per the Administrator, the staff are given in-service training, but her staff are not required to do medical functions as this is not a medical facility. Per Interviews conducted with the Administrator and Resident #4, both indicate that Resident #1 is able to feed themselves. Per the Administrator, staff will feed a Resident if they are not able to feed themselves. Staff do not refuse to feed a resident. Staff fed Resident #1 for maybe a couple of days because their hands were swollen, and they couldn’t hold the spoon. They fed Resident #1 for a couple of days before they were hospitalized on 7/27/24. Resident #1 was also constantly complaining that their oxygen concentrator was not working when it was working. Staff would show Resident #1 and their family that the oxygen concentrator was working. Resident #1 would constantly say that they are not getting their oxygen even when the oxygen concentrator was working. Based on the information received during the investigation, there was insufficient evidence to support the allegation that staff did not meet Resident #1’s care needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. The investigation into Allegation #5 - Staff is unable to communicate effectively, revealed that Staff #4 did not speak English. Per the Administrator, Staff #4 used a phone translator to communicate. Per Rebeka, Staff #4 also shared the night shift with her if they had a complicated resident who needed more care. Per Rebeka, she and Staff #4 worked together. Staff #4 would also call her if they didn’t understand something. Per Rebeka, she did not feel that the language barrier was a concern. Staff #4 no longer worked at the facility when this complaint was received and could not be interviewed for the complaint. Due to the lack of information and the unknown whereabouts of the staff, the allegation that staff is unable to communicate effectively cannot be verified. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. continued on LIC9099-C Page 7 The investigation into Allegation #6 - Staff is not properly trained and unqualified to care for residents was also investigated and training logs for 2024 were reviewed. Training logs showed that the staff received in-service training on the following dates: 1/21-Dementia (2 hours) 1/27 -Medication (4 hours), 2/12 Dementia – Behavioral changes, 2/20 Infection Control (2 hours), 3/8 dementia (2 hours), 4/17 dementia – therapeutic, rehabilitative activities (2 hours), 5/26 – dementia (2 hours), restricted and prohibited health condition (2 hours), 6/17 – Dementia (2 hours) and hospice (1 hour), 7/3 – medication (4 hours), 8/19 resident dignity, independence, privacy choices (2 hours), 8/13 Elder Abuse (2 hours), 9/16 - Covid-19, influenza and other respiratory diseases(1 hour), 9/9 Dementia: Effects of medication (1 hour), 10/7 – Dementia: hydration needs and validation therapy, 11/12- Personal and direct care (3 hours), 12/16 – Cultural competency and sensitivity (2 hours). Per interviews with the Administrator, Staff #1 and Staff #2, they all state that they receive training as caregivers. The home is a non-medical facility and staff do not perform medical services that require a medical license. Staff are also prohibited from performing medical services in the home if they do have a medical license. Per review of training records provided, there is insufficient evidence to support the allegation that staff is not properly trained and unqualified to care for residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. Per the investigation into Allegation #8 that Staff did not have planned activities for the residents, the investigation revealed that the staff are offering and providing the residents with activities such as drawing, exercises, walks making postcards, dancing, singing and board games. Many board games and activity were observed under the coffee table located in the living room. Per interview with the Administrator, she stated that the residents are offered activities, but they choose not to do any activities. Resident #1 wouldn't want to get out of bed most of the time. They cannot force the residents to do activities if they don’t want to. They prefer to watch television, use their computer or cell phone or read. Resident #6 likes to be in the living room and staff will dance, sing and do light exercises with them. This was observed during our visit on 7/23/25. Based on the information received from interviews conducted, there is insufficient evidence to support the allegation that staff did not have planned activities for the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or continued on LIC9099-C Page 2A Investigation Bureau for investigation consideration on 8/28/24. The reason for today's visit was provided. On the visit conducted on 8/28/24, LPA Yee obtained information regarding Resident's date of admission, Resident #1's length of stay at the home, services that Resident #1 was being provided during the residents stay, reason for the hospitalization and the cause of death. A copy of Resident #1's faciity files, including list of medications, MAR logs and hospice documents were requested but was not able to be provided since the copier was out of order. Per Administrator, all the requested documents will be scanned to LPA Yee by the end of today. On 8/28/24, a tour of the facility was also conducted at 2:54pm to observe the residents and to ensure that the utilities were available, review the food supply and to observe any visually obvious deficiencies. Per tour of the facility, LPA Yee observed all the residents in bed napping or watching television, sufficient perishable and non-perishable foods were observed and additional food supply is being brought in today per staff, utilities, including the air conditioner were observed to be in use. Water temperature was tested in the common and private bathroom. Water temperature tested in the common bathroom read 119.7 degrees Fahrenheit and the water temperature in the private bathroom read 119.7 degrees Fahrenheit. The swimming pool was observed to be secured by a 5 feet fence and was locked. Visually there were no immediate safety concerns observed during today's visit. Based on the 8/28/24 visit, further investigation is needed to make a finding for all of the 11 allegations currently noted as personal rights. Exit interview was conducted with Ada Bozkurt, Staff since the Administrator had to leave at 2:16pm due to child care needs. On 7/23/25, Licensing Program Analysts (LPAs) Christine Yee and Quoc Huynh conducted a subsequent joint complaint visit to investigate the above allegations and was let into the home by Crystal McKie, Staff. Staff contacted Rebeka Durgaryan, Administrator via telephone to advise of LPAs' visit and she arrived at 9:34am to conduct the visit. The reason for today's visit was provided. On today's visit, LPA Yee conducted interviews with the Administrator at 10:14am, Resident #4 at 1:40pm and Resident #6 at 2:56pm. LPA Huynh conducted interviews with Resident #3 at 2:07pm, Resident #2 at 2:13pm and conducted file reviews at 9:56am and reviewed medications at 2:21pm in conjunction with a required annual inspection. Based on the information received from interviews conducted, files and medications reviewed, it was determined that continued on 9099-C Page 3A further investigation is needed to make a finding for the above 11 Personal Rights allegations. Copies of MAR Logs, Physician Report at time of Admission, Evidence of staff training by hospice agency will be sent to LPA Yee by close of business on 7/24/25. Exit interview was conducted and a copy of the report was provided. On 7/24/25, LPA Christine Yee and Quoc Huynh conducted another joint subsequent complaint visit to continue further investigation of the above allegations and another interview with the Administrator, was conducted at 10:34am to obtain additional information regarding the hospice services, medications and assistance with meals. Also collected on today's visit were documents requested on the 7/23/25 visit. Training logs were requested for Staff #3 and Staff #4 during the interview and will be provided by 7/25/25. On 7/23/25, LPA Huynh conducted interviews with Staff #1 at 1:50pm and Staff #2 was at 1:41pm by LPA Huynh and was not noted on the report generated for that visit. Based on 7/24/25 visit it was determined that further investigation is still needed to make a finding for the above allegation. An Exit interview was conducted with Svetlana Petrosian, Staff since the Administrator had to leave to pick up supplies. On today's visit, LPA Yee delivered the complaint findings of the investigation for all eleven (11) allegations.. Per interviews conducted and review of all documents collected, the investigation revealed that Resident # 1 was formerly living in a nursing home in Richfield, Utah and was being moved to California to reside at this facility. Per review of documents from the nursing home, Resident #1 had multiple comorbidities such as congestive heart failure, cirrhosis of the liver, chronic kidney disease, major depressive disorder, chronic respiratory failure with hypoxia, Type 2 diabetes mellitus with diabetic chronic kidney disease, chronic pain syndrome, hypertension, was weak, use of a pacemaker, just to name a few. Resident #1 moved into this facility on 3/31/24 and hospice services with Elara Hospice, Inc were initiated on 4/12/24 based on Resident #1’s primary diagnosis of chronic congestive respiratory failure with hypoxia and secondary diagnosis of chronic combined systolic and diastolic heart failure. Many complaints were received that Elara Hospice was not providing Resident #1 with services due to lack of hospice staffing, family wanted to know if the doctor continued on LIC9099-C Page 4A and the hospice nurse was checking on the resident, due to the resident’s decline, the oxygen concentrator was not working, and the resident couldn’t breathe and mostly, the hospice agency’s failure to respond to the family’s concerns were received while Resident #1 was under Elara Hospice’s care. The complaint also alleges that the licensee of this facility, also owns Elara Hospice. The licensee denied owning the hospice company. The Statement of Information filed with Secretary of State also confirmed that the licensee is not the owner. The family were unhappy with the services provided by Elara Hospice, so a decision was made to transfer Resident #1’s hospice services to a hospice agency used by a friend according to the Administrator. A final comprehensive assessment report was generated by Elara Hospice in preparation for the transfer of care to Liem Hospice, was conducted. Hospice services with Liem Hospice were initiated on 6/15/24. With the transfer of hospice services, complaints continued. Per investigation into allegation #3 - Staff did not assist R1 with medication as prescribed, interview with the Administrator confirms that the facility staff did not dispense Resident #1’s medications as prescribed. However, per the Administrator, during the time that Resident #1 resided at the facility, they were not keeping Medication Administration Records (MAR log) for the residents. Per the Administrator, the only medication that was prescribed every four hours for Resident #1 was Oxycodone 5mg for pain. Oxycodone was previously prescribed on a as needed basis and due to the resident declining rapidly, Liem Hospice changed the prescription to a routine medication for management of Resident #1’s pain. Oxycodone 5mg was prescribed for every 4 hours, beginning at 8am, 12pm, 4pm, 8pm, 12am and 4am. Per the Administrator, they were able to give Resident #1 the Oxycodone doses at 8am, 12pm, 4pm and 8pm but had difficulty at 12am and 4am since the resident would be in a very deep sleep and sometimes couldn’t be woken up for the 12am and 4am doses. As a result of Resident #1 not waking up, the 2 very early morning dosages were not dispensed as prescribed. The Administrator admitted that she did not request an order change for the Oxycodone or a review of the dosage frequency to accommodate Resident #1’s sleeping needs so that medications are not missed. Per the Administrator, she spoke with the hospice doctor and the resident’s family, and she was verbally instructed not to wake the resident up. Per review of hospice notes continued on LIC9099-C Page 5A and interview conducted with hospice personnel, there were no notes to confirm that the hospice doctor gave instructions not to wake up Resident #1 to dispense the early morning medications, contrary to the standing physician's order. Resident #1 was prescribed very potent opiate medications that were required to be given in a very short span of time between doses for pain and to ensure that the resident was made comfortable. Methocarbamol 500mg, a muscle relaxant was also prescribed on top of the opiate medications. The Administrator failed to request a review of the resident’s medications or request a written change order in the frequency in which the Oxycodone dosage was to be dispensed to accommodate Resident #1’s sleep needs. On 7/13/24, Morphine Sulfate 100mg/5 ml solution, every 4 hours as needed was also prescribed and kept at the facility as part of the comfort kit if needed for emergency measures. Morphine was never prescribed as a routine medication. Per the Administrator, she and her staff do not dispense the morphine. It was part of the comfort kit and the doctor had not authorized its use. Per the Administrator, only the hospice nurse was authorized to dispense the morphine when it was determined to be needed. Per review of hospice nurse’s notes, on 7/16/24, Resident #1 was administered morphine for chest pain, on 7/25/24 morphine was administered for knee and arm pain and again on 7/26/24 for pain in the bilateral lower extremities. On the 7/26/24 hospice nurse offered the family member a fentanyl patch and it was refused. Instead, the family requested Oxycodone every 4 hours and changed the PRN frequency for Morphine 20 mg from every 4 hours as needed to every 2 hours as needed. Morphine was never prescribed as a routine medication to be given every 4 hours as noted in the complaint. No PRN Authorization letters were observed on file. Per review of hospice notes and interview with hospice personnel, there is no documentation of the hospice doctor’s instructions not to wake Resident #1 for the 12am and 4am dosage. LPA also was not able to locate any text from the family not to wake up resident, contrary to the prescribed instructions. Per hospice personnel, the only note observed was that the staff were educated in continuing to dispense the Oxycodone. Based on the interview and by own admission of the Administrator, there is sufficient evidence to support the allegation the staff did not assist R1 with medications as prescribed, therefore the allegation is substantiated at this time. Per investigation into Allegation #7 - Staff have inadequate record keeping for a resident, interview with the continued on LIC9099-C Page 6A Administrator, reveal that the facility did not keep records of Resident #1’s medications that were dispensed and missed medications. Resident #1 also had many PRN medications and there is no record that the PRN medications were dispensed or when it was dispensed, if the doctor was contacted since there is no completed PRN Authorization Letters on file from the prescribing physician that states in writing that the resident is or is not able to determine his or her need for a prescription or non-prescription medication and what instructions were given by the doctor, the dosage that was given and the results of the medications. The family were making the decisions for the PRN medications and the Administrator was going along with it. Per interview conducted with the Administrator, the hospice agency is responsible for the care of the resident. The Administrator was educated by LPA during interviews conducted, that the responsibility of all the residents that reside at the home continues to be her responsibility regardless of whether they receive hospice or home health services. The Administrator is responsible for ensuring that the residents are receiving the services noted in the care plan and aware of any changes in the resident's condition. During the investigation, It was observed that the Administrator keeps all her facility records off-site at her home and is not available for review at the time of the visit. Hospice notes were requested on 7/24/25 and again on 7/30/25 for Elara Hospice. These records had to be requested from Elara hospice and was provided on 7/31/25. The hospice agency does not maintain a file at the facility. Per investigation conducted regarding the allegation that staff have inadequate record keeping, there is sufficient evidence to support the allegation, that staff have inadequate record keeping for a resident, therefore the allegation is substantiated at this time. Failure to have completed PRN Authorization Letters were cited during the Annual Inspection conducted on 7/23/25 and will not be re-cited for this complaint. Investigation conducted for Allegation #10 - Staff is sleeping while providing care and supervision, the complaint alleges that the only staff that works 24 hours a day, 7 days a week was going to sleep at 8pm, and not changing the residents or dispensing the routine Oxycodone every 4 hours for pain to Resident #1. As a result, Resident #1 was not getting their Oxycodone as prescribed and the resident's pain level was out of control in the morning. Per interviews conducted with the Administrator, she denied that Staff #4, who worked the night shift was sleeping on the job at night when Resident #1 lived at the home and also denies current staff are sleeping on the job. Per the Administrator, she shared the night shift with Staff #4. She works the night shift if she has a resident that is complicated and needs a lot of care. LPA Yee was not able continued on LIC9099-C Page 7A to interview Staff #4 as they no longer work at the facility. However, per interviews conducted with current staff, Staff #1, who lives at the facility and does not have set hours, states that they work alone at night and admits to sleeping on the futon through the night. Staff #1 also indicates that they are a light sleeper and will wake up if the residents require assistance. Residents interviewed either indicated that they don't know if staff is asleep or awake at night and some indicated that staff responds to their calls for assistance at night However, the facility does not have a designated staff room and sleeping in a common area designated for other use is not permitted and therefore staff working the night shift can only be awake staff. Based on the information received from interviews conducted, there is sufficient evidence to support the allegation that Staff is sleeping while providing care and supervision, therefore the allegation is substantiated at this time. This deficiency was already cited during the Annual Inspection conducted on 7/23/25 and will not be re-cited for this complaint. In summary, the investigation into allegation #3 - Staff did not assist R1 with medication as prescribed, allegation #7 - Staff have inadequate record keeping for a resident and allegation #10 - Staff is sleeping while providing care and supervision reveal that there is sufficient information to substantiate all three allegations at this time. As previously noted under Allegation #7 - Staff have inadequate record keeping for a resident and Allegation #10 - Staff is sleeping while providing care and supervision, the citation was issued during the Annual Inspection conducted on 7/23/25 and is not being re-cited for this complaint. Deficiencies are cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interviews were conducted, Appeals Rights discussed and a copy was given. Page 8 did not occur, therefore the allegation is unsubstantiated at this time. Per investigation into allegation #9 - Staff made unauthorized medical decisions for the residents, it is alleged that the Administrator was making unauthorized medical decision by withholding Oxycodone from Resident #1 unless the resident asked for it, when the family complained that the resident was being over medicated when they first arrived at the facility on 3/31/24. According to the details of the complaint, the Administrator felt that the resident was taking too much Oxycodone, and made her own decision to limit Oxycodone to 2 times a day. This upset the family, since Resident #1 was used to taking for Oxycodone for many years for the pain caused by heart and kidney failure and did not have any issues. Per review of Elara Hospice notes and care plan, hospice services for Resident #1 was initiated on 4/12/24. Oxycodone 10 mg tablet every 4 hours as needed was prescribed for generalized moderate to severe body pain. The Administrator was correct in not dispensing the Oxycodone until the resident asked for it since it was prescribed as a PRN medication. Per interview conducted with the Administrator, the family told her that the nursing home had over medicated Resident #1. The Administrator vehemently denies that she told the family that she was going limit the Oxycodone to 2 pills a day when the PRN prescription indicates that Oxycodone 10 mg may be dispensed every 4 hours as needed for pain. She would never do that. Based on the investigation, there is insufficient evidence to support the allegation that Staff made unauthorized medical decisions for the residents. Although the allegations 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 at this time. Per investigation into Allegation #11 - Staff mishandled a resident, it revealed that the staff do not mishandle Resident #1. Per interview with the Administrator, she vehemently denies that she or her staff mishandles any resident. Per staff, they are gentle with the residents and treat them with respect. The residents interviewed all state that the staff do not mishandle them. They all state that the staff are great. Per interview with Resident #4, they do not have any complaints about the staff. Resident #1 was unreasonable and was mentally declining. Resident #1 blew things out of proportion. Resident #1’s legs and feet swell up and they were always in pain and taking pain medication. Resident #1 would tell the family that they were being mishandled and of course they believed the resident. That’s their mother, why would Resident #1, not be continued on LIC9099-C Page 9 believed. The staff have to touch Resident #1, who was always in pain, in order to change them. Based on the information received from interviews conducted, there is insufficient evidence to support the allegation that staff mishandled a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. In summary, the investigation into allegation #1-Staff neglect resulted in R1's death, allegation #2 -Staff did not seek timely medical attention for a resident, allegation #4 - Staff did not meet R1's care needs, allegation #5 - Staff is unable to communicate effectively, allegation #6 - Staff is not properly trained and unqualified to care for residents, allegation #8 - Staff did not have planned activities for the residents, allegation #9 - Staff made unauthorized medical decisions for the residents and allegation #11 - Staff mishandled a resident, there was insufficient evidence to support all the above eight (8) allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore all the above eight (8) allegations are unsubstantiated at this time. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 29-AS-20240827151722

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 6, 2025

Incidental Medical and Dental care: .......(2) Once ordered by the physician the medication is given according to the physician's directions. Staff failed to dispense R1's Oxycodone at 12am and 4am as prescribed. This requirement was not met as evidenced by Staff dispensed R1's Oxycodone at 8am, 12pm,4pm, 8pm and failed to dispense R1's Oxycodone at 12am and 4am as prescribedthe state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The licensee will ensure that the residents are given their medications as prescribed. Licensee will submit a written plan of action to the Department as to how they will ensure that all residents are given their medication as prescribed or what actions will be taken to ensure prescribed medications are not missed. Submit the plan of action to the Department by 8/6/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(3) · Plan of correction due date: Aug 6, 2025

Incidental Medical and Dental care: If the resident's physician has stated in writing that the resident is unable to determine his/her own need...A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.This requirement was not met as evidenced by: Resident #1 was prescribed PRN Oxycodone while under the care of Elara Hospice and was dispensed by staff. However, the facility did not document the date, time, dose given and the response.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The licensee will read Title 22, Section 87465 in entirety and provide a written statement that the section was read and provide a written plan of action as to how they will ensure that dispensed PRN medications are documented and available to the Department for review. by 8/6/25 of the resident

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Quoc Huynh and Christine Yee arrived at the facility unannounced to conduct a subsequent visit in conjunction with complaint # 29-AS-20240827151722. The LPAs met with the Staff, explained the reason for the visit, and Staff notified the Licensee. The Licensee Rebeka Durgaryn arrived at 10:28AM. Entrance interview conducted. Upon entering the facility, the LPAs observed a drawer with knives to be accessible. The drawer was unlocked with the key in the keyhole and the additional exterior locking mechanism was not attached. At 10:30AM, LPA Huynh and Staff conducted a brief tour of the physical plant to ensure there were no health and safety hazards. The LPA observed the knife drawer to be secured during the tour. No additional immediate concerns were observed. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D). An immediate civil penalty in the amount of $250 for a repeat citation was issued (refer to LIC 421FC). The Licensee was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the Appeal Rights and today's report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 25, 2025

(a) Except as specified in subsection (b), the licensee shall ensure that ... knives, ... sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in the drawer containing knives were accessible which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Staff secured the drawer during the visit. The Licensee will review regulations, update Staff training, and submit a statement of understanding with Staff and Licensee signatures by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:02AM. The LPA met with Staff #1 (S1), explained the reason for the visit, and they notified the Licensee. The Licensee Rebeka Durgaryan arrived at 9:35AM. Entrance interview conducted. Beginning at 9:14AM, the LPA and S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The facility is a single-story residential home. The following was observed: COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The living room had a screened fireplace that was inoperable. Required postings were observed in the living room. Locked file cabinets were observed near the dining table and contained files and medications. The facility maintained a comfortable temperature throughout the visit. There was a laundry room located in the hallway of the rear exit. Laundry machines were observed to be operational and locked cabinets contained detergent and cleaning supplies. BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each with dual occupancy. Bedrooms #1 and #2 had direct exits to the outside, with Bedroom #1 approved for one (1) bedridden resident. Report Continued on LIC 809-C Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinet. There were two (2) total restrooms in the facility: one (1) private restroom attached to Bedroom #2 that is utilized by Staff and one (1) shared resident restroom located in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. LPA observed an unlocked cabinet in the resident restroom that contained cleaning supplies. The Staff stated they forgot to lock it and was planning on cleaning when the LPA arrived. The Staff immediately secured the cabinet. Hot water was tested in the resident restroom and measured at 149 degrees F which is not within the required range of 105 degrees F and 120 degrees F. KITCHEN: The LPA observed knives stored inaccessible in a locked drawer and the drawer’s front panel was falling off its screws. The Staff stated they did not notice the condition of the drawer. Cleaning supplies were locked under the kitchen sink. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. Emergency water was not observed and the Licensee stated they did not have any. The Staff and Licensee stated the refrigerator in the Kitchen is broken and a new one will be arriving by 07/25/2025. Food is temporarily stored in the refrigerators and freezers in the rear patio which were observed to be properly stored with labels and dates. OUTDOOR AREA: The rear of the facility had an Additional Dwelling Unit occupied by the Licensee. The LPA observed a fenced off pool, however, the gate was not secured. The gate was left ajar at a 40-degree angle and was observed to have a lock that was not in use. The Licensee stated the Staff must have forgotten to lock the pool gate and proceeded to lock the gate. The pool area had two (2) sheds that contained extra facility supplies and general storage. There was one (1) side gate that led to the front yard and was an emergency exit for Bedroom #2. The pool area was also accessible through the side yard and the Licensee stated they removed the gate that separated the pool area from the side yard as a Plan of Corrections on a prior visit. Report Continued on LIC 809-D Prior citation in regard to securing the pool was not found. The Licensee stated they will re-install the gate. The LPA also observed exposed electrical wires along the side yard’s wall and a hole on the wooden ramp utilized by Bedroom #2. The surrounding rear had one (1) shaded patio area equipped with furniture in good condition for resident and visitor use. The front yard had a driveway with an operated gate as well as a door for everyday use. The opposite side of the property had a driveway used as an emergency exit that also led to the front yard. The LPA observed a brown bed frame in the front yard, obstructing the side exit. The Licensee stated it was a brand-new bed that they were planning to replace for a resident; however, the bed was broken. RECORDS: Record review began at 9:56AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Records were in order with Staff training missing hours. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 04/10/2025. Smoke and carbon monoxide detectors as well as the fire door were tested at 9:47AM. The fire door did not latch when released, and was observed to be stuck inside the mechanism. The Licensee stated that smoke alarms were recently replaced and tested, and they did not have this issue. The Licensee called a technician out to the facility, and fixed the latch. MEDICATIONS: Medication review began at 2:21PM. Medications were centrally stored and kept inaccessible. Medications were observed for three (3) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. Report Continued on LIC 809-C Resident #1 (R1) and Resident #2 (R2) were prescribed PRN (as needed) medications and the Licensee did not have a PRN Authorization Letter on file, or records of when and why the PRN medication was administered. Additionally, interview with S1 and the Licensee revealed that they crush Resident #3’s (R3) medications and put it in R3’s food because R3 has trouble swallowing. The Licensee did not have orders from a physician to crush R3’s medications and stated when R3 was previously on Hospice, that was the orders, but R3 is no longer on Hospice. Three (3) Staff and four (4) residents were interviewed. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jul 23, 2025

Type of visit: Case Management - Deficiencies

LPA Yee conducted an unannounced case management visit due to the deficiencies observed during a visit to the facility today. LPA Yee initially with Rebeka Durgaryan, Administrator and later with Ada Bozkurt, Staff after the Administrator had to leave for child care reasons. The reason for the visit was provided. During today's visit, LPA Yee observed the following: - the facility did not notify the Department when the facility initiated hospice services for Resident #1(R1), Resident #4(R4) and Resident #5(R5) within 5 of initiation of services. - the facility did not report Resident #1's hospitalization or death to the Department. - Resident #7 was observed in a hospital bed equipped with a full bed rail and an exception for the use of the full bed rail was not requested or granted and needs to be removed until the exception request has been submitted for consideration and is granted. Deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8the state’s words, verbatim · CDSS document, Aug 28, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Sep 4, 2024

Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements. The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...... R1, R4 & R5 are on hospice and was not reportedthe state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Licensee will read Title 22 Section 87632 and 87633 and submit a written statement that the sections were read and understood and that the Licensee will comply with all requirements noted in the Section. Licensee will also submit written hospice notification letters containing all the required information noted in the Section being cited to the Department by 9/4/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(A) · Plan of correction due date: Aug 30, 2024

Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below. A) Death of any resident from any cause regardless of where the death occurred, including..... a hospital, en route to or from a hospital, or visiting away from the facility. Resident #1's death was not reported to the Departmentthe state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: The Licensee will ensure that all resident deaths, whether it occurred in the faciity or away from the facility in a hospital is reported to the Depatment. Licensee will complete an LIC624A for the death of Resident #1 and submit to the Department by no later than 8/30/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 30, 2024

Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. R1's hospitalization wasn't reportedthe state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Licensee will ensure that all incidents which threatens the welfare, safety or health of any resident, including hospitalizations are reported to the Department. Licensee will complete an LIC624 to report the hospitalization of R1 by 8/30/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Aug 29, 2024

Postural Support: Based on the individual's preadmission appraisal, and subsequent changes to that appraisal.... Postural supports may be used under the following conditions.Under no circumstances shall postural supports include tying, depriving, or limiting the use . of a resident's hands or feet.Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. R7's hospital bed was observed equipped with a full bed rail. (not on hospice)the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Licensee will immediately remove the full bed rail and submit evidence that the full bed rails have been removed by 8/29/24.

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Naira Aghajanyan, Staff. Staff contacted the Administrator via telephone and she arrived at 11:14am to conduct the visit. The reason for today's visit was provided. The facility is a single storey home consisting of a living room, dining room, kitchen, 3 bedrooms and 2 full bathrooms and a fenced in swimming pool. Located in the back of property is a separate 2 storey building. The facility has a fire clearance for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #1 is the approved room for bedridden use. The following domains were reviewed on today's visit: Infection Control, Physical Plant and Environmental Safety, Residents Rights-Information, Food Service, Disaster Preparedness (partial). 7 staff files and 6 resident files were reviewed. Due to time constraints the remaining domains will be reviewed on a return visit. On today's visit, the following were observed: The living room, dining room and kitchen had the appropriate furnishings. Sufficient perishable foods and sufficient non-perishable foods were observed The common bathroom was observed with grab bars and a non-skid mat. The water temperature was tested and it read 117.1 degrees Fahrenheit. The water temperature was tested in the private bathroom and the it read 121.4 degrees Fahrenheit. The hardwired smoke/carbon monoxide detector and smoke detectors were tested and were operational. The cleaning solutions are stored in a locked cabinet under the kitchen sink Medications are stored in a locked cabinet located in the dining room knives are locked in a kitchen drawer. trash cans were observed with tightly sealed lids. The facility was observed to be clean, inside and outside The pool was observed enclosed with a rod iron fence and was locked. Any deficiencies not cited on today's visit will be addressed on a return visit. Exit interview was conducted with Ada Bozkurt, a Copy of the appeals rights was providedthe state’s words, verbatim · CDSS document, Jul 19, 2024