Facility Evaluation Report

Licensing Program Analyst (LPA) Gary Tan initially met staff Hasmik Gevorgyan who called the co- Administrator Andranik Ter-nersesian for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. The co Administrator designated Ms. Gevorgyan to sign the report.

A tour of the physical plant was conducted at 12:32 PM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. The facility has a designated visitors' area at the front yard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) bedrooms and two (2) bathrooms currently occupying six (6) residents. One (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which may be bedridden on Room #2 . Hospice waiver for four (4) residents.

Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the dining area and observed to be full and last bought on 10/30/25.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 809-C)