Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee conducted the visit with Emma Kochinyan, Administrator and the reason for the visit was provided.

The home is a single family home consisting of a living room, a dining room, a kitchen, a family room, 3 resident bedrooms, 2 bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY residents and 1 BEDRIDDEN resident.

Due to time constraints the following domains were completed on today's visit: Infection Control Practices, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information,

Planned Activities, Food Service and Incidental Medical and Dental. The remaining 4 domains will be addressed on a return visit.

During today's visit, LPA Yee reviewed all 4 staff files, residents' files, perishable and non-perishable food supply and medications. Citations were issued as a result of the deficiencies observed.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any citations not addressed on today's visit will be addressed on a return visit.

Exit Interview was conducted, Appeals Rights discussed and a copy was provided.