Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not confirmed. The most recent report from August 26, 2025, was a complaint investigation with no deficiencies found. Earlier reports showed some issues, including substantiated findings of insufficient staffing and delayed response to call buttons in July 2024, as well as repeated fire clearance violations for non-ambulatory residents on upper floors resulting in a $1,000 fine in December 2024. The facility addressed these issues with plans to relocate residents and improve compliance. There is a clear pattern of improvement over time, with recent investigations showing no substantiated deficiencies.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 0
Aug 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that a resident was receiving additional incidental medical care unrelated to their health condition and that facility staff bullied a resident.
Findings
The investigation included interviews with residents, staff, and the executive director, as well as a review of records and observation. Both allegations were found to be unsubstantiated due to insufficient evidence and lack of supporting information from interviews and records. No health or safety issues were noted during the visit.
Complaint Details
The complaint involved two allegations: 1) Resident receiving additional incidental medical care unrelated to their health condition, and 2) Facility staff bullying a resident. Both allegations were investigated through interviews, record reviews, and observations and were deemed unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 4
Complaint control number: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation |
| Varsenik Keshishyan | Executive Director | Facility administrator interviewed during the investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 175
Deficiencies: 0
Aug 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not ensure the facility was kept clean, safe, and sanitary, specifically regarding a strong odor coming from a resident's bathroom.
Findings
The investigation found no evidence of foul odors or unsanitary conditions during the physical plant tour, interviews with staff and residents, and inspection of the resident's bathroom. The allegation was unsubstantiated due to insufficient information to verify the claim.
Complaint Details
The complaint was unsubstantiated after investigation. The Licensing Program Analyst conducted interviews with staff and residents, inspected the facility, and found no foul odors or unsanitary conditions as alleged.
Report Facts
Capacity: 175
Census: 79
Staff interviewed: 6
Residents interviewed: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Varsenik Keshishyan | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 175
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-04-10 regarding staff response times to call signals and rough handling of a resident.
Findings
The investigation found that staff responded to the resident's emergency call within a reasonable time frame, and the allegation of rough handling was unsubstantiated based on interviews, observations, and record reviews. No health and safety issues were noted at the time of the visit.
Complaint Details
The complaint involved two allegations: 1) staff did not respond to the call signal system in a timely manner, and 2) staff handled a resident in a rough manner. Both allegations were investigated through interviews with staff and residents, record reviews, and observation. Both allegations were deemed unsubstantiated.
Report Facts
Call signal response times: 81
Call signal response times: 189
Residents interviewed: 8
Staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Met with Licensing Program Analyst during the complaint investigation and signed the amended report |
| Leizl De La Cerra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 175
Deficiencies: 0
Apr 30, 2025
Visit Reason
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be generally well-maintained with no health or safety hazards noted. The physical plant, medication storage, fire safety equipment, and resident rooms were all in compliance. The facility was currently housing 72 residents with a licensed capacity of 175.
Report Facts
Facility capacity: 175
Resident census: 72
Fire extinguisher last inspection date: Apr 14, 2025
Hot water temperature: 113.2
Days of perishable food stocked: 2
Days of non-perishable food stocked: 7
Resident rooms: 125
Fire clearance capacity ambulatory: 100
Fire clearance capacity non-ambulatory: 75
Bedridden capacity: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Met with Licensing Program Analyst during inspection |
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 86
Capacity: 175
Deficiencies: 0
Jan 29, 2025
Visit Reason
The visit was a plan of correction inspection to verify correction of deficiencies issued during the last visit on 2024-12-26.
Findings
During the tour, the Licensing Program Analyst observed that bedrooms were clean and residents were happy with their new rooms. Plan of correction letters were issued during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Met with Executive Director during plan of correction visit. |
| Charles Brugh | Executive Director | Met with Licensing Program Analyst during plan of correction visit. |
Inspection Report
Census: 70
Capacity: 175
Deficiencies: 0
Dec 26, 2024
Visit Reason
The unannounced Case Management: Health and Safety visit was conducted to discuss the recent fire inspection visit by the Glendale Fire Department and address fire clearance issues related to non-ambulatory residents on upper floors.
Findings
The facility is not in compliance with Title 22 regulations regarding approved fire clearance, as non-ambulatory and bedridden residents are residing on the 2nd, 3rd, and 4th floors without appropriate fire clearance. The Glendale Fire Department denied the request to increase non-ambulatory and bedridden counts on upper floors, requiring these residents to remain on the 1st floor or have direct outside access. The facility plans to relocate affected residents accordingly. No other immediate health and safety issues were observed.
Report Facts
Bedridden residents allowed per previous fire clearance: 5
Non-ambulatory residents allowed per previous fire clearance: 75
Ambulatory residents allowed per previous fire clearance: 100
Current census: 70
Total licensed capacity: 175
Non-ambulatory residents on 2nd, 3rd, and 4th floors: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charles Brugh | Executive Director | Met during inspection and discussed fire clearance issues. |
| Naira Margaryan | Licensing Program Manager | Conducted the inspection and explained non-compliance with fire clearance regulations. |
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the inspection and explained non-compliance with fire clearance regulations. |
| Angelica Segovia | Licensing Program Analyst | Conducted the inspection and explained non-compliance with fire clearance regulations. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 175
Deficiencies: 1
Dec 26, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility was not following approved fire clearance for non-ambulatory residents residing on upper floors.
Findings
The investigation substantiated that non-ambulatory residents, including resident #1, were residing on the 2nd to 4th floors without approved fire clearance, posing an immediate health and safety risk. The facility was informed of an additional immediate civil penalty of $1,000 due to repeated violations within 12 months.
Complaint Details
The complaint was substantiated. It was confirmed that non-ambulatory residents were residing on floors not approved by the Fire Department. The facility was issued an immediate civil penalty of $1,000 due to repeated violations within 12 months.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility does not have approved fire clearance for non-ambulatory residents to reside on the 2nd to 4th floors, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 1000
Number of residents interviewed: 10
Number of non-ambulatory residents: 10
Plan of Correction due date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation. |
| Naira Margaryan | Licensing Program Manager | Conducted the complaint investigation. |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation. |
| Charles Brugh | Interim Administrator | Met with investigators during the complaint visit. |
Inspection Report
Census: 75
Capacity: 175
Deficiencies: 6
Sep 24, 2024
Visit Reason
An unannounced Case Management Visit was conducted to issue citations and civil penalties for deficiencies observed during a prior Licensing Visit.
Findings
Deficiencies included operating an 'Independent Living Plus' program without prior approval, improper placement of non-ambulatory residents on upper floors without approved fire clearance, and failure to update residents' physician reports and service plans as needed.
Severity Breakdown
Type A: 1
Type B: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility implementing an 'Independent Living Plus' program without prior approval from the Licensing Department. | Type B |
| Non-ambulatory residents housed on the second and third floors without approved fire clearance for the second floor. | Type A |
| Residents' physician reports and needs and services plans are not being updated as needed. | Type B |
| Non-ambulatory residents residing in rooms approved only for ambulatory residents. | Type B |
| Facility does not have a current, written definitive plan of operation submitted to licensing, including significant changes such as the 'Independent Living Plus' program. | Type B |
| Pre-admission appraisals are not being submitted in writing as frequently as necessary to note significant changes and keep appraisals accurate. | Type B |
Report Facts
Capacity: 175
Census: 75
Plan of Correction Due Date: Sep 25, 2024
Plan of Correction Due Date: Oct 8, 2024
Plan of Correction Due Date: Oct 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager conducting the inspection and cited in the report |
| Rosaura Valenzuela | Licensing Program Analyst | Named as Licensing Program Analyst conducting the inspection and cited in the report |
| Charles Brugh | Interim Administrator | Met with during the inspection visit |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 1
Jul 24, 2024
Visit Reason
This case management visit was conducted in conjunction with a complaint investigation to address issues unrelated to the complaint, specifically to evaluate staffing sufficiency and response to resident call buttons.
Findings
The facility was found to have insufficient staffing as evidenced by delayed caregiver response times to resident call buttons and failure of staff to reset call buttons during testing. A citation was issued under Title 22 Regulations, but no immediate health and safety hazard was noted at the time of the visit.
Complaint Details
The visit was conducted in conjunction with a complaint investigation. The issues addressed in this visit were unrelated to the complaint. Insufficient staffing was substantiated based on observations and interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were insufficient in numbers and failed to meet the needs of resident (R1) when call button was pressed, posing an immediate health and safety risk. | Type A |
Report Facts
Response time to call button: 8
Response time to call button: 4
Staff interviewed: 6
Staff admitted insufficient staffing: 3
Plan of Correction Due Date: Jul 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the case management and complaint investigation visit |
| Nichelle Gillyard | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
| Edemida Vasquez | LVN | Met with during the inspection |
| Varsenik Keshishyan | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 1
Jul 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-06-13 regarding staff not ensuring residents' pendants and call buttons were in good repair and not seeking medical attention in a timely manner.
Findings
The investigation substantiated the allegation that staff did not respond promptly to residents' pendants and emergency call buttons, posing a potential health and safety risk. However, the allegation that staff did not seek medical attention in a timely manner was unsubstantiated based on interviews, observations, and record reviews.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure residents' pendants and call buttons were in good repair and responded promptly. The allegation that staff did not seek medical attention in a timely manner was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff did not respond to 1 out of 3 emergency devices, posing a potential health and safety risk to persons in care. | Type A |
Report Facts
Residents interviewed: 14
Staff interviewed: 6
Emergency devices tested: 3
Response time: 8
Response time: 4
Unanswered call duration: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation report |
| Edemida Vasquez | Licensed Vocational Nurse (LVN) | Facility staff member met during inspection |
| Varsenik Keshishyan | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 83
Capacity: 175
Deficiencies: 0
Jul 11, 2024
Visit Reason
Licensing Program Analyst Rosaura Valenzuela conducted an unannounced required 1-year annual inspection to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be operating within capacity limits with no health and safety issues noted. Fire clearance, carbon monoxide and smoke detectors were all compliant and operable. Resident rooms were properly furnished, medicines securely stored, and environmental safety measures such as grab bars and nonskid mats were in place.
Report Facts
Nonperishable food supply: 7
Perishable food supply: 2
First aid kits: 5
Hot water temperature range: 105
Hot water temperature range: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Met with Licensing Program Analyst during inspection |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the inspection |
| Naira Margaryan | Licensing Program Manager | Named in report |
Inspection Report
Census: 83
Capacity: 175
Deficiencies: 0
Jul 11, 2024
Visit Reason
This Case Management Visit was conducted to address issues discussed during the Annual Inspection and to review the implementation of a new program called 'Assisted Living +', including resident relocations from Independent Living to Assisted Living+.
Findings
The facility has implemented a new program and relocated residents requiring minimal care from the 3rd floor to the 2nd floor. The Executive Director was advised to ensure residents' personal rights are respected regarding relocations and to submit an addendum to the program plan reflecting these changes.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Informed about resident relocation and program changes during the visit. |
| Naira Margaryan | Licensing Program Manager | Participated in phone discussion regarding facility changes. |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the visit and advised on resident rights and program plan submission. |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 0
Apr 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the provider refused to honor existing Continuing Care Contracts.
Findings
The investigation found that the provider, Ararat, is fully aware of and obligated to honor existing continuing care contracts following the sale of the facility. There was no evidence of failure to fulfill these obligations, and the allegation was found to be unfounded.
Complaint Details
The complaint alleged that the provider refused to honor existing Continuing Care Contracts. The investigation concluded the allegation was unfounded.
Report Facts
Capacity: 175
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Hadley | Evaluator | Conducted the complaint investigation |
| Allison Nakatomi | Licensing Program Manager | Named in report signature section |
| Varsenik Keshishyan | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 0
Apr 4, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that staff mishandled a resident and threw a resident's soiled undergarment at their face while in care.
Findings
The investigation found no injuries or witnesses, and the incident occurred in the Skilled Nursing portion of the campus overseen by CDPH. Based on the information obtained, the allegations were deemed unfounded, meaning they were false, could not have happened, or lacked reasonable basis.
Complaint Details
The complaint involved allegations that Staff 1 was rough while changing Resident 1 and threw the resident's soiled underwear at them. The administrator self-reported the incident to CDPH, Ombudsman, and Law Enforcement. The complaint was investigated and found to be unfounded.
Report Facts
Complaint Control Number: 31
Capacity: 175
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Varsenik Keshishyan | Administrator | Facility administrator who was met during the investigation and self-reported the incident |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 175
Deficiencies: 1
Mar 29, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation initiated due to an allegation of rodent infestation at the facility.
Findings
The investigation substantiated the allegation of rodent infestation based on staff and resident interviews and record reviews. Rodent droppings were observed during a prior Department of Public Health inspection, and the facility took corrective actions including deep cleaning, fumigation, and pest control services. The facility was cleared to resume kitchen operations after reinspection.
Complaint Details
The complaint was substantiated. The allegation was that the facility had an infestation of rodents, confirmed by evidence including rodent droppings found during a Department of Public Health inspection and staff and resident interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303 Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met due to rodent infestation. | Type B |
Report Facts
Staff interviewed: 8
Residents interviewed: 9
Capacity: 175
Census: 96
Food license suspension duration: 48
Pest control service dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Administrator | Met with Licensing Program Analyst during investigation |
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation |
| Angela J Kendrick | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 101
Capacity: 175
Deficiencies: 0
Feb 21, 2023
Visit Reason
The inspection was conducted as a pre-licensing evaluation for a Change in Ownership (CHOW) application for a Continuing Care Residential Community (CCRC) with a requested capacity of 175 residents.
Findings
During the pre-licensing inspection, no deficiencies or non-compliance issues were observed. The facility was found to be in substantial compliance with applicable laws and regulations, and no follow-up inspection is required.
Report Facts
Fire clearance capacity: 100
Fire clearance capacity: 70
Fire clearance capacity: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Administrator | Met with Licensing Program Analyst during pre-licensing evaluation |
| Troy Agard | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Angela J Kendrick | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 35
Capacity: 175
Deficiencies: 0
Nov 7, 2022
Visit Reason
The visit was an office type evaluation involving a telephone interview to verify the applicant/administrator's understanding of California Code Title 22 Regulations and readiness for licensing.
Findings
The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness during the COMP II telephone interview.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Administrator | Participated in COMP II interview and confirmed understanding of regulations. |
| Derik Ghookasian | COO | Participated in COMP II interview. |
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