Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted a Pre-Licensing Inspection with Administrator Victoria Hayrapetyan and Licensee Ani Tigranyan. A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on December 3, 2024. A fire clearance was approved on March 19, 2025, for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. All bedrooms are cleared for one bedridden resident. A dementia plan of operation has been submitted. A hospice waiver has been requested for six (6) residents pending the Manager's approval. The smoke alarms and carbon monoxide detector are battery-operated and functional. The fire extinguisher is located in the kitchen with a purchase date of 04/15/25.

A tour of the physical plant was initiated at approximately 9:45 am and the following was observed:

KITCHEN : The facility has a Kitchen area equipped with a refrigerator, microwave oven, and sink. Adequate supplies of perishable and nonperishable food and dining ware accommodated a maximum capacity of six (6). Medications are kept locked in storage cabinet next to the fire extinguisher in the kitchen.

BEDROOMS : There are five (5) bedrooms designated for residents' use. Bedrooms #2, #3,#4, and #5 are designated for private use. Bedroom#1 is a shared bedroom. The rooms are furnished with beds, nightstands, chairs, dressers, bedding, and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has two (2) bathrooms for the residents' use. One is located in the main hallway and one private in Room #2. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. Water temperature in the bathrooms measured between 105-109 degrees F . No cleaning supplies or hazardous items were present in each bathroom. (Continue on 809C)