Facility Evaluation Report

On 5/7/2026 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct the required Annual Inspection. Upon arrival, LPA was greeted by the Staff, who granted access to the facility. LPA explained the reason for the visit. LPA Khurshudyan reviewed the required postings posted on the entrance wall and throughout the facility. Administrative Assistant Viktorya Hayrapetyan arrived shortly after. At approximately 10:05am LPA requested staff and residents’ rosters for review.

The inspection tool was used to complete the visit.

At 10:35pm LPA, with the help of the Staff, began a physical plant tour of the facility and the following was observed: This is a single-story building with four (4) bedrooms, and all rooms are designated for residents’ use only. There are three (3) bathrooms, a kitchen, common areas: living and dining rooms, and an outdoor area. Facility has an approved fire clearance for six (6) non-ambulatory residents, all of which one (1) may be bedridden for bedroom #4, and a Hospice waiver approval for six (6) residents.

Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. No expired food was observed. Facility stores knives and sharps inside the locked kitchen cabinet. Sufficient amount of emergency supply of food / water was readily available inside the kitchen cabinet. Food storage and preparation areas are clean and inaccessible to pests. LPA observed one (1) fire extinguisher located on the kitchen wall. The fire extinguisher was last serviced on 6/13/2025. Dish soap and other chemicals were observed to be stored under the sink inside the locked cabinet and inaccessible to residents in care.