Facility Evaluation Report

On 4/29/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the Administrator Serozh Kirakosyan and stated the reason for their visit.

LPA asked for the census. The Administrator stated that there are zero (0) residents. LPA conducted a physical plant tour at approximately 10:30 AM and the following was noted:

The facility is a single-story building with four (4) bedrooms and three (3) bathrooms currently occupying zero (0) residents. There is no designated staff room. The facility has an approved fire clearance for six (6) non-ambulatory residents of which one (1) may be bedridden. Hospice waiver for six (6). Sign in sheet, hand sanitizer, gloves and masks are available upon entrance.

Common areas: The living room and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 71°F. LPA observed a fire extinguisher to be located in the kitchen and dated 04/29/2025. LPA observed required postings such as See/Say Something, Emergency Disaster Plan, and Personal Rights located alongside the dining room leading towards the kitchen. A fireplace was observed to be covered and inaccessible to residents.

Kitchen: The kitchen was observed to be clean and free from pests. Knives/sharps were observed to be kept in a locked kitchen cabinet. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C)