Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection. LPA met with Staff, Vanisa Campbell, and explained the purpose of the visit. Licensee/Administrator, Kristina Adamyan, arrived shortly after to assist with the visit. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. Bedroom #3 is approved for bedridden. Facility has a hospice waiver approved for 5 residents.

LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed:

Infection Control: The facility has an Infection Control Plan posted. Staff are continuing to clean and disinfect the home daily. They are wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time. Physical Plant & Environment Safety: The facility consists of 4 resident rooms, 2 bathrooms, staff office area, living room, dining room, kitchen, and detached garage. The backyard has a shaded area for resident use. There are no swimming pool or bodies of water on the premises. The facility has a carbon monoxide detector located in the hallway near the kitchen. There are no items obstruction the hallways or ramps. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator.

Staffing : All staff members have current CPR & First Aid certificates. Per the licensee, there is sufficient staffing and has backup staffing if needed.

Personnel Records-Training : LPA reviewed 3 personnel files. The administrator's (Kristina Adamyan) certificate expires on 12/28/26. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, employee rights form, and in-service training. Staff also have sufficient number of training hours for dementia care.