Facility Evaluation Report

Licensing Program Analyst (LPA) Huma Rahimi, met with the staff Keneshbek Minzhasharov , and the Administrator Marine Grigoryan was contacted via phone and LPA explained the reason for the case management visit. The purpose of the case management visit is to address deficiencies observed during the course of complaint # 31-AS-20250516105015, The deficiencies were not alleged but observed by LPA.

During the visit, LPA was informed that R1 is having behavior issues/incidents on daily basis. Furthermore, on 05/02/2025, R1 had a bowel movement incident. On 03/27/25, R2 was taken to the hospital by calling 9-1-1 for shortness of breath. However, no incident reports were submitted to the Community Care Licensing Department (CCLD) in a timely manner for R1 and R2. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident/Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

LPA informed the Administrator to submit an incident report that occurred on:

Moreover, upon arrival to the facility LPA conducted interviews and concluded that two (2) out of two (2) staff were not able to communicate in English with the residents of which the majority speak English. Furthermore, interviews with five (5) out of six (6) residents who were able to communicate confirmed that