Facility Evaluation Report

Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, the LPA met with Designee Marine Arshakyan, and explained the reason for the visit.

At 12:45 p.m., the LPA observed the Los Angeles Fire Department (LAFD) at the facility transporting Resident #1 (R1) to the hospital. The LPA inquired with Designee Marine Arshakyan the reason for the ambulance being called. The Designee advised that the resident was new at the facility, and had issues with their catheter. The LPA asked the Designee if R1 is receiving Hospice or Home Health services, and the Designee stated “no.” At 1:03 p.m., the LPA contacted Administrator Asmik Nadrian via telephone to inquire if R1 is receiving Hospice or Home Health services; the Administrator stated, “no Hospice or Home Health.” The LPA advised the Administrator that under Title 22 Regulation 87623 (a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders. At 1:12 p.m., the LPA observed Room #4 had two (2) residents residing in the bedroom. The LPA asked Resident #2 (R2) if they were residing in the room with Resident #3 (R3) as a roommate. R2 confirmed that the facility staff relocated R2 to room #4. The facility currently has the room numbers on the resident bedroom doors differing from the Facility Sketch, and room #4 at this time is displaying a #3 not in accordance with the Fire clearance nor submitted Facility Sketch. The LPA advised the Designee that the facility has an approved Fire Clearance for five (5) non-ambulatory residents total in rooms 1 (shared), 2 (shared), and 3 (shared); and, one (1) bedridden resident only in room #4 (private). The LPA also advised the Designee that the facility is in violation of Title 22 Regulation section 87203 Fire Safety, as the facility failed to maintain in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.