Facility Evaluation Report

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Avetis Keshishyan, Staff at 10:27am. Julietta Mirzoyan, Administrator was contacted by telephone and she arrived at 10:58am to conduct the visit. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, a kitchen, four resident bedrooms, 2 full bathrooms and a detached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #4 is designated for 1 bedridden resident use. The facility is also approved for 5 hospice waivers.

On today's visit, all 12 domains of the Care Inspection Tool was reviewed. The following was observed for the physical plant:

The living room was furnished with the appropriate furniture and seating for 6 residents. The fire place was sealed off with a cover. Above the fire place was a mounted television. The outside exiting door is equipped with a auditory device and leads out to a ramp.

The front door is equipped with an auditory device that was operational.

The dining room was furnished with a table and 6 chairs,

The kitchen was observed with a stove with an oven, microwave, toaster oven, toaster and a refrigerator. A cabinet containing resident and staff files was observed. Cleaning solutions and dish soaps were stored in a locked cabinet under the sink. Knives were stored in a locked drawer. The only fire extinguisher purchased on 11/30/24 was observed in the kitchen.

Bedroom #1 was furnished with 2 hospital beds, 2 night stands, 2 chairs, 2 lamps, a shared dresser and a built in closet. Window dressings was observed. The beds were not made up as it was vacant.