Facility Evaluation Report

At 9:30 a.m. on 06/19/25, Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit.

Today’s case management visit was conducted to ensure the health and safety of facility residents and the facility’s compliance to Title 22 Regulations.

LPM and LPA interviewed staff and residents between 9:40 a.m. and 11:30 a.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 9:45 a.m., and toured the facility inside and out at 11:15 a.m.

Interview with Staff #1 (S1) at approximately 10:45 a.m. revealed that Staff #2 (S2) was a live-in staff. S1 further noted that Resident #1 (R1) was recently admitted. The facility moved Resident #2 (R2) into the staff room when R1 was admitted. Facility tour revealed two beds were set up in the staff room. Record review revealed R1 was admitted to the facility on 06/06/25. A deficiency is issued for a resident sleeping in the staff room. During the facility tour, LPA observed Resident #3 (R3) was residing in Bedroom #2. Record review of R3’s medical assessment revealed they are bedridden. File review of the facility’s fire clearance at 11:15 a.m. today revealed Bedroom #3 was designated for a bedridden resident. Interview with S1 revealed R3 has been residing in Bedroom #2 for over two (02) years. A deficiency is issued for violating the facility’s fire clearance by placing a bedridden resident in a non-ambulatory room which was not designated for bedridden residents. Other deficiencies were discovered during this visit which will be cited at a later date.

Exit interview conducted. Appeal rights discussed. Copy of report provided.