Deficiencies (last 5 years)
Deficiencies (over 5 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
46% occupied
Based on a February 2026 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 81
Capacity: 175
Deficiencies: 0
Date: Feb 9, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 2026-01-15 regarding staff not seeking timely medical attention, neglect causing pressure injury, inadequate nutrition, and uncomfortable living accommodations for a resident.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to seek timely medical attention, neglect causing pressure injury, inadequate nutrition, and uncomfortable living accommodations. None of these were verified by the investigation.
Findings
The investigation included interviews with residents, staff, and review of medical and facility records. All allegations were found to be unsubstantiated based on interviews, observations, and record reviews, with no evidence supporting the claims of neglect or inadequate care.
Report Facts
Residents interviewed: 13
Census: 81
Total capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Najwa Elwan | Wellness Director | Met with during investigation and received report copy |
| Varsenik Keshishyan | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 0
Date: 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.
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.
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.
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: 78
Capacity: 175
Deficiencies: 0
Date: Aug 26, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations that a resident was receiving additional incidental medical care unrelated to their health condition and that facility staff bullied a resident.
Complaint Details
The complaint investigation was triggered by allegations that Resident #1 was given medical care unrelated to their condition and that staff bullied the resident. Interviews with residents and staff, as well as record reviews, did not support these claims. The complaint was deemed unsubstantiated.
Findings
After interviews, observations, and record reviews, both allegations were deemed unsubstantiated due to insufficient evidence. No health and safety issues were noted during the visit.
Report Facts
Residents interviewed: 10
Staff interviewed: 4
Allegations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 175
Deficiencies: 0
Date: 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.
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.
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.
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: 79
Capacity: 175
Deficiencies: 0
Date: Aug 11, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to 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.
Complaint Details
The complaint was unsubstantiated after investigation. The allegation involved a strong odor in a resident's bathroom, but no evidence was found to support the claim.
Findings
The investigation included interviews with staff and residents, a physical plant tour, and inspection of the alleged area. No foul odors or unsanitary conditions were observed or reported by others. The allegation was determined to be unsubstantiated due to insufficient evidence.
Report Facts
Census: 79
Total Capacity: 175
Staff interviewed: 6
Residents interviewed: 11
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 |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 175
Deficiencies: 0
Date: 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.
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.
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.
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
Complaint Investigation
Census: 77
Capacity: 175
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not respond to call signals in a timely manner and that staff handled a resident in a rough manner.
Complaint Details
The complaint involved two allegations: 1) staff did not respond to call signal system in a timely manner, and 2) staff handled a resident in a rough manner. After investigation including interviews, record reviews, and observation, both allegations were found unsubstantiated.
Findings
The investigation found that staff responded to the resident's emergency call within a reasonable time frame, and interviews with staff and residents confirmed timely assistance. There was no sufficient evidence to verify the allegation that staff handled the resident roughly. Both allegations were deemed unsubstantiated.
Report Facts
Call signal response times: 81
Call signal response times: 189
Residents interviewed: 8
Staff interviewed: 4
Residents census: 77
Facility capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Leizl De La Cerra | Licensing Program Analyst | Conducted complaint investigation and authored report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 175
Deficiencies: 0
Date: 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
Annual Inspection
Census: 72
Capacity: 175
Deficiencies: 0
Date: 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 clean, well-maintained, and compliant with safety and health standards. No health and safety hazards were noted, medication was securely stored, and fire safety equipment was up to date.
Report Facts
Resident rooms: 125
Fire clearance capacity: 100
Fire clearance capacity: 75
Bedridden capacity: 5
Food stock duration: 2
Food stock duration: 7
Facility temperature: 73
Hot water temperature: 113.2
Fire extinguisher last inspection date: Apr 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Met with Licensing Program Analyst during the inspection |
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Plan of Correction
Census: 86
Capacity: 175
Deficiencies: 0
Date: 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
Plan of Correction
Census: 86
Capacity: 175
Deficiencies: 0
Date: 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 confirmed residents needing room changes from ambulatory to non-ambulatory and observed clean bedrooms with residents satisfied with their new rooms. Plan of correction letters were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Brugh | Executive Director | Met with Licensing Program Analyst during plan of correction visit. |
Inspection Report
Census: 70
Capacity: 175
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
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.
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: 70
Capacity: 175
Deficiencies: 1
Date: 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 the facility's non-compliance with approved fire clearance for non-ambulatory residents on upper floors.
Findings
The facility was found not in compliance with Title 22 regulations regarding fire clearance, as non-ambulatory residents were 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 all such 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.
Deficiencies (1)
Facility retains non-ambulatory residents on upper floors without approved fire clearance.
Report Facts
Bedridden count: 5
Non-ambulatory count: 75
Ambulatory count: 100
Current census: 70
Total capacity: 175
Non-ambulatory residents on upper 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 visit |
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the inspection visit |
| Angelica Segovia | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 175
Deficiencies: 1
Date: 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.
Complaint Details
The complaint was substantiated. The allegation was that the facility was retaining non-ambulatory residents on floors not approved by the Fire Department. The investigation confirmed this violation and an immediate civil penalty of $1,000 was issued due to a repeat violation within 12 months.
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. Interviews, record reviews, and physical plant tours supported the allegation.
Deficiencies (1)
Facility does not have approved fire clearance for non-ambulatory residents to reside on the 2nd to 4th floors, violating CCR 87202.
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 Evaluator | Conducted the complaint investigation and authored the report. |
| Angelica Segovia | Licensing Program Analyst | Participated in the complaint investigation and facility tour. |
| Naira Margaryan | Licensing Program Manager | Participated in the complaint investigation and interviews. |
| Charles Brugh | Interim Administrator | Met with investigators during the complaint visit. |
| Nichelle Gillyard | Supervisor | Supervised the complaint investigation. |
Inspection Report
Census: 75
Capacity: 175
Deficiencies: 6
Date: 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.
Deficiencies (6)
Facility implementing an 'Independent Living Plus' program without prior approval from the Licensing Department.
Non-ambulatory residents housed on the second and third floors without approved fire clearance for the second floor.
Residents' physician reports and needs and services plans are not being updated as needed.
Non-ambulatory residents residing in rooms approved only for ambulatory residents.
Facility does not have a current, written definitive plan of operation submitted to licensing, including significant changes such as the 'Independent Living Plus' program.
Pre-admission appraisals are not being submitted in writing as frequently as necessary to note significant changes and keep appraisals accurate.
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
Census: 75
Capacity: 175
Deficiencies: 5
Date: 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 the second and third floors without approved fire clearance, and failure to update residents' physician's reports and needs and services plans as required.
Deficiencies (5)
Facility implementing an 'Independent Living Plus' program without prior approval from the Licensing Department.
Non-ambulatory residents housed on the second and third floors without approved fire clearance for the second floor.
Non-ambulatory residents residing in rooms approved only for ambulatory residents.
Failure to maintain a current, written definitive plan of operation and submit significant changes to licensing.
Failure to update residents' physician's reports and needs and services plans as needed.
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 | Supervisor overseeing the inspection and cited deficiencies. |
| Rosaura Valenzuela | Licensing Program Analyst | Licensing evaluator conducting the inspection. |
| Charles Brugh | Interim Administrator | Facility representative met during the inspection. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: 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.
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.
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.
Deficiencies (1)
Staff did not respond to 1 out of 3 emergency devices, posing a potential health and safety risk to persons in care.
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
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not ensure residents' pendants and call buttons were in good repair and did not seek medical attention to residents in a timely manner.
Complaint Details
The complaint investigation was initiated due to allegations that staff failed to ensure residents' pendants and call buttons were in good repair and did not seek medical attention promptly. The allegation regarding pendants and call buttons was substantiated, while the allegation regarding timely medical attention was unsubstantiated.
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.
Deficiencies (1)
Staff did not respond to 1 out of 3 emergency devices, posing a potential health and safety risk to persons in care.
Report Facts
Capacity: 175
Census: 78
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 |
| Edemida Vasquez | License Vocational Nurse | Facility staff member met during inspection and involved in findings |
| Varsenik Keshishyan | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 1
Date: 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.
Complaint Details
The visit was conducted in conjunction with a complaint investigation. The case management visit addressed issues unrelated to the complaint. The facility was found to have insufficient staffing based on observations and staff interviews.
Findings
The facility was found to have insufficient staffing as evidenced by delayed and missed responses to resident call buttons during inspection. A citation was issued under Title 22 Regulations, but no immediate health and safety hazard was noted at the time of the visit.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, specifically failing to respond timely to resident call buttons.
Report Facts
Staff response time: 8
Staff response time: 4
Staff interviewed: 3
New staff hired: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the case management and complaint investigation visit |
| Nichelle Gillyard | Supervisor | Named in relation to the inspection and report |
| Edemida Vasquez | LVN | Met with during the inspection |
Inspection Report
Annual Inspection
Census: 83
Capacity: 175
Deficiencies: 0
Date: 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
Date: 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
Annual Inspection
Census: 83
Capacity: 175
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
An unannounced required 1-year annual inspection was conducted by Licensing Program Analyst Rosaura Valenzuela to evaluate the facility's compliance with regulations.
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 compliant and operable. Resident rooms were properly furnished, medicines securely stored, and safety features such as grab bars and nonskid mats were in place. Food storage and diet quality met requirements.
Report Facts
Capacity: 175
Census: 83
First aid kits: 5
Nonperishable food supply: 7
Perishable food supply: 2
Hot water temperature range: 105-120
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 | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Census: 83
Capacity: 175
Deficiencies: 0
Date: 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 within the facility.
Findings
The facility has begun implementing the 'Assisted Living +' program, relocating residents requiring minimal care from the Independent Living 3rd floor to the 2nd floor. Concerns were raised about resident personal rights regarding relocations and the need to submit program changes as an addendum to the facility plan.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Executive Director | Informed about resident relocation and program implementation; discussed resident rights and relocation decisions. |
| Naira Margaryan | Supervisor | Contacted by phone to discuss facility changes and program plan. |
| Rosaura Valenzuela | Licensing Evaluator | Conducted the visit and advised on resident rights and program plan submission. |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 0
Date: 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.
Complaint Details
The complaint alleged that the provider refused to honor existing Continuing Care Contracts. The investigation concluded the allegation was unfounded.
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.
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
Capacity: 175
Deficiencies: 0
Date: Apr 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the provider refused to honor existing Continuing Care Contracts.
Complaint Details
The complaint alleged that the provider refused to honor existing Continuing Care Contracts. The investigation concluded the allegation was unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the provider 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.
Report Facts
Capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Hadley | Evaluator | Conducted the complaint investigation |
| Varsenik Keshishyan | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 0
Date: 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.
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.
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.
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: 86
Capacity: 175
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The inspection 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.
Complaint Details
The complaint involved allegations of staff mishandling a resident and throwing a soiled undergarment at the resident's face. The allegations were investigated and found to be unfounded.
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.
Report Facts
Facility capacity: 175
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Administrator | Met during investigation and advised of complaint |
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 175
Deficiencies: 1
Date: Mar 29, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation initiated due to an allegation of rodent infestation at the facility.
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.
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.
Deficiencies (1)
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.
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
Complaint Investigation
Census: 96
Capacity: 175
Deficiencies: 1
Date: Mar 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation initiated due to an allegation of rodent infestation at the facility.
Complaint Details
The complaint was substantiated. The allegation was that the facility had an infestation of rodents, supported by evidence including rodent droppings found during a Department of Public Health inspection, staff and resident interviews, and pest control records.
Findings
The investigation substantiated the allegation of rodent infestation based on staff and resident interviews, and record reviews including pest control invoices and a Department of Public Health inspection report. The facility had rodent droppings observed in the kitchen and storage areas, but subsequent cleaning, fumigation, and pest control measures were implemented, and the facility was cleared to resume kitchen operations.
Deficiencies (1)
87303 Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by rodent droppings observed within the facility.
Report Facts
Capacity: 175
Census: 96
Staff interviewed: 8
Residents interviewed: 9
Food license suspension duration: 48
Pest control service dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Varsenik Keshishyan | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation |
| Angela J Kendrick | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Original Licensing
Census: 101
Capacity: 175
Deficiencies: 0
Date: 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
Original Licensing
Census: 101
Capacity: 175
Deficiencies: 0
Date: 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, with no items requiring follow-up inspection.
Report Facts
Fire clearance capacity: 175
Water temperature: 111.4
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 evaluation visit |
| Angela J Kendrick | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 35
Capacity: 175
Deficiencies: 0
Date: 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. |
Inspection Report
Census: 35
Capacity: 175
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
The visit was an office type evaluation involving a telephone interview with the applicant/administrator to verify identification and confirm understanding of California Code Title 22 Regulations as part of the Community Care Licensing process.
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 | Applicant/administrator who participated in COMP II interview and confirmed understanding of regulations. |
| Derik Ghookasian | COO | Participant in COMP II interview. |
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