Facility Evaluation Report

On February 12, 2026, Licensing Program Analyst Sandra Urena and Licensing Program Manager KaSandra Lopez met with Satenik Alajanyan for an Office Meeting. During this meeting, a Case Management Deficiencies report was issued in conjunction with a complaint visit (Complaint Control # 29-AS-20260127125601). The purpose of this report is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s meeting the LPA explained the reason for the report.

During the course of the investigation, it was discovered that a resident who was admitted to the facility on 01/21/2026, following discharge from a medical center, was admitted without the proper documentation (pre-appraisal) to assess the needs of the resident prior to admission. Furthermore, the administrator did not conduct formal admission process and did not complete the required Community Care Licensing forms to create a resident’s file and did not meet nor communicate with the resident’s responsible party, which poses / posed an immediate health, safety or personal rights risk to persons in care.

During the walk through of the facility at approximately 11:05 a.m., the LPA observed that a resident in bedroom # 2 was in bed with full bed rails. The bed rails were raised at the time of the visit. When the LPA asked the administrator to provide the doctor’s orders for the full bed rails, the administrator was unable to provide the documentation and/or doctor’s order for the full bed rails.