Facility Evaluation Report

On 6/3/2026 at approximately 1:30pm, Licensing Program Analyst (LPA), Perchui Milena Khurshudyan conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. The Licensee/Staff, Hamazasp Khudoyan arrived shortly after to assist with today’s visit.

LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 2:00 PM and the following was noted:

The facility is a single-story building with six (6) bedrooms, six (6) bathrooms. The facility is currently occupying four (4) 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 approved for four (4). All bedrooms are approved for bedridden, however, 1 at a time. There are three licensed RCFEs on the property.

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 72°F. LPA observed two (2) fire extinguishers located throughout the facility and dated 1/7/2026. LPA observed required postings such as Long-Term Care Ombudsman, Emergency Disaster Plan, and Personal Rights alongside the entrance leading towards the kitchen. A working telephone was observed.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives/sharps were observed to be kept in a locked box, placed on the kitchen countertop. The cleaning solutions/toxins were observed to be kept under the sink, inside a locked cabinet. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C)