Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced Case Management visit due to a deficiency that was observed during the Annual Inspection conducted on 3/12/26. The deficiency was not addressed during the Annual Inspection due to the need for clarification from the Fire Inspector for the fire clearance granted during the application process. LPA Yee was let into the home by Naira Aghajanyan, Staff. Rebeka Durgaryan, Administrator, was contacted and she arrived at 4:17pm to conduct the visit. The reason for today's visit was provided.

Per review of the fire clearance (STD850) granted on 1/21/21 and the facility sketch that was submitted with the request for a fire clearance of the home during the application process, the back three bedrooms were approved for six (6) non-ambulatory residents of which one (1)may bedridden. The facility sketch identifies the bedrooms as Bedroom #1, Bedroom #2 and Bedroom #3. Per the facility sketch, Bedroom #1 and Bedroom #3 do not have direct exit doors to the outside. Bedroom #2, which is located at the very back of the home, has a direct exit door that leads on to a ADA approved ramp. Based on the setup of Bedroom #2, the room is designated and approved for one (1) bedridden resident. A fire rated door was installed at the end of the hallway that leads from the living room to the three(3) bedrooms located in the back to allow the retention of non-ambulatory residents in Bedroom #1 and Bedroom #3 as there is no door to allow direct exit to the outside. The fire rated door would allow the residents to exit from the door located in the den. Per review of the facility sketch, the room previously identified as an office and the front staff bedroom also do not