Facility Evaluation Report

Licensing Program Analyst (LPA) Brian Balisi and Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250620153333). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation unrelated to the complaint. Upon arrival, LPAs met with staff and explained the reason for the visit. LPA's contacted Licensee Sarkis Dovlatyan who stated they will contact their Administrator Arshalouis Manoukian. Manoukian arrived shortly after.

On 06/20/2025, the Department received a complaint alleging questionable death of Resident #1 (R1). The case was referred to Community Care Licensing Division’s (CCLD) Investigations Branch (IB) and assigned to Investigator Michele Salant. On 09/15/2025, the RO obtained copies of Emergency Medical Service (EMS) reports along with 9-1-1 audio recordings and transcripts for the facility dating back to six (6) months. A review of the EMS reports, 9-1-1 recordings and transcripts revealed two (2) additional questionable deaths, Resident # 2 (R2), Resident #3 (R3), that were not reported to the department.

According to the EMS reports reviewed, upon paramedics’ arrival on 05/16/2025 at 9:58 a.m., R2 was noted to be unconscious, cold to touch, in lividity and Dead on Arrival (DOA). Per the facility staff, R2 was last seen approx. 14 hours prior. Staff observed R2 to be unresponsive and not breathing in the morning when attempting to change R2s diaper. Moreover, according to EMS, it was notated that the resident was found in supine position, laying in bed in a state of “rigor, as well as lividity.” On 05/30/2025 at 11:03 a.m., Paramedics arrived at the facility and observed R3 unresponsive, pale, DOA in obvious rigor and lividity. Staff noted that R3 was last seen approx. 5 hours ago.