Facility Evaluation Report

Licensing Program Analyst (LPA) Sandra Urena conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-29-AS-20250821122539). The purpose of the visit is to issue citations for the deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA spoke with the Administrator Satenik Alajanyan and explained the reason for the visit.

During the course of the investigation, it was discovered that the Administrator had not submitted an Incident Report to the Community Care Licensing Department to inform them of the elopement of R1 on 08/19/2025. The Administrator stated that they were contacted by a Social Worker (SW),( Administrator did not know full name of SW or agency affiliation) on Thursday 08/21/2025, letting them know that R1 was at the hospital. The Administrator stated that because the SW informed them that R1 was in the hospital, the Administrator did not consider it necessary to send the LIC 624 to CCL. Furthermore, in the course of the investigation, the LPA discovered that R1’s file had incomplete forms (LIC 602) Medical Assessment: (LIC 602) - Missing Physician’s diagnosis, no phone number. No contact phone number for the physician and Staff’s (S1) record review revealed that S1 did not have a CPR and First Aid certificate on file.

Pursuant to Title 22, California Code of Regulations and CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Citations were issued. Exit interview was conducted with the Amy Vetinyan, the Administrator's acquaintance due to the Administrator being unavailable via person or telephone. The Administrator allowed the staff to sign off on the report. A copy of the report and Appeal Rights were issued.