Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced visit at this facility for a One (1) year Required visit. LPA met with staff Maria Rivera who called the Licensee Andranik Khunkayan and explained the purpose of the visit. The administrator is doing an assessment at this time. License's wife around twenty (20) minutes later.

A tour of the physical plant was conducted at 12:36 PM. The facility has a total of five (5) bedrooms and two (2) bathrooms. One of the room is designated for staff use only. The facility is a one (1) storey building on the hill with the garage underneath. There is also a lift located just outside the garage for non-ambulatory and wheelchair bound resident. The facility fire cleared for six (6) non-ambulatory residents, one of which may be bedridden in Room #3. Hospice waiver for six (6) residents. 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 Mitigation plan and Infection plan.

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 75°F. The carbon monoxide and smoke detector are tested and observed to be operational. Smoke detectors are hardwired and interconnected. Fire extinguisher was observed to be full and last bought on 06/03/25.

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