Facility Evaluation Report

At 10:00 a.m., Licensing Program Analyst (LPA), Evelin Rios conducted an unannounced Case Management - Incident visit in response to a self reported Unusual Incident Report submitted to Community Care Licensing (CCL). LPA met with the Program Director, Marine Guloyan and spoke to the Executive Director, Armen Melikyan over the phone and explained the reason for the visit is to investigate an Unusual Incident reported by the facility.

At 10:15 a.m., LPA requested copies of relevant documents pertaining to the investigation, including, but not limited to, the following: resident #1's (R1's) physician’s report, admission agreement, pre placement assessment, appraisal needs and services plan, resident and staff roster and staff #1's (S1's) records. LPA also reviewed a copy of the facility’s camera footage for the day in question. Licensee is working on providing a copy to LPA. At approximately 11:28 a.m., LPA conducted a physical plant tour, to ensure health and safety of the clients in care. Program Director was informed further investigation is required at this time.

Exit interview conducted and copy of this report signed and delivered.