Inspection Reports for
Belmar Villa Assisted Living
2020 N Weber Ave, Fresno, CA 93705, CA, 93705
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
62% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 62
Capacity: 100
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
An unannounced Case Management Annual Continuation visit was conducted to complete items from a previous visit on 10/16/2025, including staff file review, resident records review, and completion of the care tool.
Findings
No deficiencies were cited during this inspection. The licensee was instructed to submit updated documents including liability insurance, LIC 500, and LIC 9020 by 11/26/2025.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with during the inspection visit. |
Inspection Report
Annual Inspection
Census: 62
Capacity: 100
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
The inspection was an unannounced annual required inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be comfortable, odor-free, and well-furnished with adequate seating and televisions. Food supplies and fire safety equipment were in place. Due to time constraints, medication review and file reviews were deferred to a later date.
Inspection Report
Complaint Investigation
Census: 62
Capacity: 100
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-05-30 regarding staff response to resident requests and theft of resident belongings.
Complaint Details
The allegations investigated were that staff did not respond to resident's request for assistance in a timely manner and that staff stole resident’s personal belongings. The allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. No deficiencies were issued during the complaint visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 100
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of neglect/lack of care and failure to provide snacks for residents in care.
Complaint Details
The complaint investigation was unsubstantiated due to insufficient information to confirm the allegations of neglect and failure to provide snacks.
Findings
The investigation found insufficient evidence to prove or disprove the allegations; therefore, the allegations were unsubstantiated and no deficiencies were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Capacity: 100
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
An unannounced Case Management visit was conducted for the purpose of assessing the health and safety of the residents in care.
Findings
The facility was observed to be well lit with a comfortable temperature. Food supply and seating were adequate, and no deficiencies were cited during the visit.
Inspection Report
Complaint Investigation
Census: 64
Capacity: 100
Deficiencies: 2
Date: Feb 6, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate multiple allegations regarding resident care and facility operations at Belmar Villa.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to rotate residents in bed, missed doctor's appointments, denial of physician choice, untimely medical attention, failure to provide all meals, inaccessible call bells, unclean floors, lack of dignity and respect, and inadequate food alternatives. Most allegations were unsubstantiated except for four which were substantiated based on observations and interviews.
Findings
Several allegations were investigated, with most found to be unsubstantiated due to insufficient evidence. However, four allegations were substantiated, including call bells being out of reach, unclean resident floors, lack of dignity and respect in care, and inadequate food alternatives for residents with allergies. No deficiencies were cited for some substantiated allegations due to prior citations.
Deficiencies (2)
CCR 87468.1 Personal Rights of Residents: Residents must be accorded dignity in personal relationships. Resident 2 was observed wearing only a brief with the door open, violating privacy and dignity.
CCR 87303(i)(1) Maintenance and Operation: Facilities must have signal systems accessible to residents. Call buttons were observed to be out of reach for several residents, posing a health and safety risk.
Report Facts
Capacity: 100
Census: 64
Plan of Correction Due Date: Feb 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Facility administrator involved in investigation and exit interviews |
| Sarah Hurt | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Brenda Chan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 100
Deficiencies: 2
Date: Feb 4, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including failure to safeguard residents' personal items, facility disrepair, and inadequate food service.
Complaint Details
The complaint investigation was initiated based on allegations received on 2024-06-03. The allegation that staff were not safeguarding residents' personal items was unsubstantiated. The allegations that the facility was in disrepair and that food service was inadequate were substantiated.
Findings
The allegation regarding safeguarding residents' personal items was unsubstantiated due to lack of evidence. The allegations of facility disrepair and inadequate food service were substantiated based on observations and resident interviews, resulting in cited deficiencies.
Deficiencies (2)
CCR 87303(a) Maintenance and Operation: The facility was not clean, safe, sanitary, and in good repair as evidenced by lifted flooring, overflowing trash bins without lids, and dirty laundry on resident bedroom floors.
CCR 87555(a) General Food Service Requirements: The facility failed to provide food of adequate quality and quantity, as residents reported not eating due to dislike of food and lack of adequate substitutions.
Report Facts
Capacity: 100
Census: 64
Deficiencies cited: 2
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 65
Capacity: 100
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The inspection was an unannounced annual required inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was observed to be well maintained, with adequate food supply, proper safety equipment, and secure medication storage. No deficiencies were cited during the inspection.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 100
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-08-06 regarding staff behavior and facility conditions.
Complaint Details
The complaint included allegations that staff spoke to residents inappropriately and failed to provide medications as prescribed, and that the facility had recurrent power outages affecting resident oxygen, mold in resident rooms, and dirty air conditioning vents. The investigation found no evidence to support these claims and dismissed the complaint as unsubstantiated and unfounded.
Findings
The investigation found insufficient evidence to substantiate the allegations. The department determined the allegations were unsubstantiated or unfounded and no deficiencies were cited.
Report Facts
Facility Capacity: 100
Resident Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during the investigation and named in the report |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 100
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-05-02 regarding facility cleanliness and food service quality.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not ensure restrooms were clean and sanitized. The allegation regarding inadequate food service was unsubstantiated due to lack of evidence.
Findings
The investigation substantiated that facility staff did not ensure restrooms were clean and sanitized, specifically noting mold in community showers. Another complaint about food service quality was unsubstantiated due to insufficient evidence.
Deficiencies (1)
CCR 87303(a)(1) requires the facility to be clean, safe, sanitary, and in good repair at all times. The facility failed to keep community showers free from mold, posing a potential health and safety risk to residents.
Report Facts
Capacity: 100
Census: 65
Plan of Correction Due Date: Jul 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Makaryan Hripsime | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Capacity: 100
Deficiencies: 2
Date: Jun 28, 2024
Visit Reason
The visit was an unannounced office meeting conducted due to the number of complaints and deficiencies the facility has had over the past year, including three type A deficiencies.
Findings
The facility had issues including lack of supervision, full bedrails, poor maintenance and sanitation, failure to meet residents' care needs, staff not providing comfortable accommodations, staff not addressing residents' change of condition, and absence of a home health care plan for a resident.
Deficiencies (2)
The facility had a lack of supervision and full bedrails were present. The facility was not maintained or sanitary and did not meet residents' care needs.
Staff did not provide comfortable accommodations and failed to address residents' change of condition. There was no home health care plan for a resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with during the inspection and named in the report narrative. |
| Les Xiong | Licensing Evaluator | Named as licensing evaluator conducting the report. |
| Melinda Hoffmann | Supervisor | Named as supervisor during the inspection. |
Inspection Report
Follow-Up
Census: 69
Capacity: 100
Deficiencies: 0
Date: Apr 12, 2024
Visit Reason
The visit was an unannounced case management follow-up to review an incident involving resident R1.
Findings
No deficiencies were issued during the inspection. The Licensing Program Analyst reviewed the resident file and conducted an exit interview with the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during the inspection and acknowledged receipt of the report. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-01-08 regarding staff drugging and physically abusing a resident.
Complaint Details
The complaint alleged staff drugged a resident and physically abused a resident. The allegations were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Records review, staff and resident interviews, and observations indicated residents' care was provided according to their needs.
Report Facts
Capacity: 100
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during investigation and involved in records review and interviews |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 100
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-01-08 alleging that facility staff did not provide supervision resulting in a resident being left on the floor.
Complaint Details
The complaint alleged lack of supervision resulting in a resident being left on the floor. The allegation was unsubstantiated after investigation and interviews.
Findings
The investigation included interviews with staff and the administrator and a tour of the facility. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with records showing residents were checked every 30 minutes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during investigation and named in findings discussion |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Supervisor | Named as supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that due to lack of supervision, a resident eloped from the facility.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews. The allegation was that due to lack of supervision, a resident eloped from the facility. The resident was sent to the hospital for evaluation after being located.
Findings
The investigation substantiated the allegation that the facility failed to provide adequate supervision, allowing a resident to elope unassisted. The facility did not know the resident had left until the family arrived, posing an immediate health and safety risk.
Deficiencies (1)
CCR 87464(f)(1) Basic services require care and supervision to prevent endangerment. The facility failed to follow physician orders by allowing a resident to elope unassisted, and staff were unaware the resident had left until family arrived.
Report Facts
Facility Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Named in relation to the elopement incident and investigation |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 100
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of missing medication reported on 12/22/2023.
Complaint Details
The complaint alleging missing medication was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found that the allegation of missing medication was unfounded. The resident was able to manage and administer their own medication as per physician's report, and no deficiencies were cited.
Report Facts
Capacity: 100
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Hripsime Makaryan | Administrator | Facility administrator involved in the complaint visit |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 1
Date: Jan 23, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility was not meeting residents' care needs, resulting in multiple falls causing bruising.
Complaint Details
The complaint was substantiated. The allegation that the facility failed to meet resident care needs resulting in multiple falls causing bruising was confirmed by evidence.
Findings
The allegation was substantiated based on interviews and record reviews which confirmed that a resident requiring 1:1 care did not receive it 24/7 from October to December 2023. A deficiency was issued for failure to provide adequate direct care staff as required by California Code of Regulations.
Deficiencies (1)
CCR 87705(c)(4): Licensees who accept and retain residents with dementia must ensure an adequate number of direct care staff to support each resident's safety and health care needs. The facility did not provide 1:1 care staff to meet R1's needs as identified in R1's current appraisal, posing a potential health and safety risk.
Report Facts
Capacity: 100
Census: 68
Plan of Correction Due Date: Jan 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Named in relation to the complaint investigation and exit interview |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 100
Deficiencies: 0
Date: Jan 3, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2023-12-06 regarding medication mismanagement, failure to safeguard personal items, and unaddressed inappropriate sexual interaction between residents.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Mai Yang. Allegations included medication mismanagement, failure to safeguard personal items, and unaddressed inappropriate sexual interaction between residents. The findings were unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. Medication destruction timing and resident movements were noted, but no evidence supported the claims of inappropriate sexual interaction or failure to safeguard personal items. The allegations were determined to be unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during investigation and named in report |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 100
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was restrained in bed.
Complaint Details
The complaint investigation was substantiated for the allegation that Resident 1 was restrained in bed. The allegation that Resident 1 was locked in a room was unsubstantiated.
Findings
The allegation that Resident 1 was restrained in bed with full bed rails without written orders was substantiated. Another allegation that Resident 1 was locked in a room was unsubstantiated due to lack of evidence.
Deficiencies (1)
CCR 87608(a)(5) Postural supports shall not include tying or limiting use of resident's hands or feet. Resident 1's bed had full bed rails without hospice orders, posing a safety risk.
Report Facts
Capacity: 100
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during inspection and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 100
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations received on 2023-10-09 regarding facility cleanliness and resident grooming.
Complaint Details
The complaint investigation was substantiated for the allegation of unclean and unsanitary conditions but unsubstantiated for the allegation of lack of grooming assistance.
Findings
The allegation that staff do not maintain the facility clean and sanitary was substantiated based on observations of dirty laundry and malodorous conditions in Resident 1's room. The allegation that staff do not assist Resident 1 with grooming was unsubstantiated due to insufficient evidence.
Deficiencies (1)
CCR 87303(a) requires the facility to be clean, safe, sanitary, and in good repair at all times. Resident 1's room had a large pile of laundry and smelled of urine, posing an immediate health and safety risk.
Report Facts
Capacity: 100
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during investigation and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 73
Capacity: 100
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
The inspection was an unannounced Annual Continuation inspection conducted by the Licensing Program Analyst to assess compliance with licensing requirements.
Findings
No deficiencies were cited during this inspection. The Licensing Program Analyst completed the inspection tool and conducted an exit interview with the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during inspection. |
| Malia Thao | Licensing Program Analyst | Conducted the Annual Continuation inspection. |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Census: 73
Capacity: 100
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
The inspection was an unannounced case management visit regarding a Decision and Order to exclude employee S1 from the facility.
Findings
The Licensing Program Analyst confirmed that S1 was not working in the facility since earlier this year. No deficiencies were cited during this inspection.
Inspection Report
Annual Inspection
Census: 75
Capacity: 100
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility, observed adequate furnishings, food supplies, and safety equipment. No deficiencies were cited during this inspection.
Inspection Report
Complaint Investigation
Census: 72
Capacity: 100
Deficiencies: 3
Date: Sep 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 05/12/2023 regarding inadequate resident accommodations, failure to address a resident's medical condition, and lack of a home health plan on file.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not provide comfortable accommodations, failed to address a resident's medical condition, and lacked a home health plan on file. The complaint was unsubstantiated for allegations of staff neglect causing a pressure injury, unexplained injury, and improper facility maintenance.
Findings
The investigation substantiated that staff failed to provide comfortable accommodations, did not address a resident's change in medical condition, and lacked a home health plan for the resident. However, allegations related to staff neglect causing a pressure injury, unexplained injury, and improper facility maintenance were unsubstantiated.
Deficiencies (3)
CCR 87465(a)(2) The licensee did not provide necessary medical assistance between 5/1/23 and 5/10/23 when home health did not conduct wound care visits and the facility did not seek medical treatment for the resident's wound.
CCR 87468.1(a)(2) The facility failed to provide safe, healthful, and comfortable accommodations as a resident was found lying on a plastic covered mattress with no bedding, one sock on their feet, and an undressed wound on 5/11/23.
CCR 87609(b)(4) The licensee and home health agency did not have a written agreement on responsibilities, and the facility lacked a copy of the home health care plan, leaving them unaware of care responsibilities.
Report Facts
Facility Capacity: 100
Resident Census: 72
Deficiency Count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during investigation and signed receipt of documents |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 67
Capacity: 100
Deficiencies: 0
Date: May 15, 2023
Visit Reason
The inspection was an unannounced case management visit to return files that were removed during an earlier inspection.
Findings
No deficiencies were cited during this inspection. The Licensing Program Analyst returned the complete file for R1 and conducted an exit interview with the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during inspection. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 100
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a case management - incident visit following special incident reports received for incidents occurring on 11/29/22 and 12/4/22.
Complaint Details
The visit was triggered by special incident reports related to a power outage affecting residents using oxygen concentrators and a resident found on the floor. The incidents were reviewed and no deficiencies were cited.
Findings
The inspection found that during a power outage, three residents using oxygen concentrators were safely transferred to the hospital. Another resident was found on the floor without injury. No deficiencies were cited during this inspection.
Report Facts
Residents using oxygen concentrators: 3
Incident dates: Incidents occurred on 11/29/22 and 12/4/22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malia Thao | Licensing Program Analyst | Conducted the case management - incident inspection |
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst and provided incident information |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 100
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations of financial abuse and personal rights violations received on 2022-10-14.
Complaint Details
The complaint involved allegations of financial abuse and personal rights violations. The investigation concluded these allegations were false, could not have happened, and/or were without reasonable basis.
Findings
The investigation found no evidence that financial abuse or personal rights violations occurred. The allegations were determined to be unfounded.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malia Thao | Licensing Program Analyst | Conducted the complaint investigation. |
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during investigation. |
Inspection Report
Annual Inspection
Census: 66
Capacity: 100
Deficiencies: 3
Date: Nov 21, 2022
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing regulations and facility operations.
Findings
The inspection identified three deficiencies: an employee working without criminal record clearance, a window sill in room 309 lifted with exposed nails, and waste baskets and trash cans without tight-fitting lids. A civil penalty of $500 was assessed.
Deficiencies (3)
CCR 87355(e)(1) Criminal Record Clearance: An employee was working at the reception desk without criminal record clearance, posing an immediate health and safety risk.
CCR 87303(a) Maintenance and Operation: The right side of the window sill in room 309 was lifted with exposed nails, posing a potential health and safety risk.
CCR 87303(f)(3) Maintenance and Operation: All bedroom and bathroom waste baskets and hallway trash cans lacked tight-fitting lids, posing a potential health or personal rights risk.
Report Facts
Civil penalty amount: 500
Inspection Report
Complaint Investigation
Census: 66
Capacity: 100
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
The inspection was conducted as a case management visit to address observations made during a complaint inspection related to staff behavior towards a resident.
Complaint Details
The visit was complaint-related based on complaint #24-AS-20221014092112. The complaint was substantiated by the Licensing Program Analyst's observation of staff yelling at a resident.
Findings
A deficiency was cited for violation of residents' personal rights due to a staff member yelling at a resident, posing an immediate personal rights risk. A Plan of Correction was developed with the administrator.
Deficiencies (1)
CCR 87468.1(a)(3) requires residents to be free from punishment, humiliation, intimidation, abuse, or punitive actions. During the complaint inspection, a staff member was heard yelling at a resident while trying to take them for dinner, posing an immediate personal rights risk.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during inspection and involved in Plan of Correction |
| Malia Thao | Licensing Program Analyst | Conducted the inspection and cited deficiency |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not properly supervising residents in care.
Complaint Details
The complaint alleging improper supervision of residents was investigated and found to be unsubstantiated.
Findings
The investigation found the allegation to be unsubstantiated due to lack of preponderance of evidence showing residents were not properly supervised.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Hripsime Makaryan | Administrator | Met with the Licensing Program Analyst during the investigation. |
| Sergiy Pidgirny | Supervisor named in the report. |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint alleging that a resident machine was not being cleaned regularly and that a resident was malodorous.
Complaint Details
The complaint investigation was conducted for allegations that a resident machine was not being cleaned regularly and that a resident was malodorous. The first allegation was found to be unfounded and the second unsubstantiated.
Findings
The investigation found the allegation that the resident machine was not cleaned regularly to be unfounded, as staff cleaned the tubes daily. The allegation that a resident was malodorous was unsubstantiated due to insufficient evidence to prove or disprove the claim.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit and delivered investigation findings. |
| Hripsime Makaryan | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: Jun 9, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations including resident falls, diet restriction noncompliance, lack of activities, medication mismanagement, inadequate food service, lack of supervision, and failure to execute emergency disaster plans.
Complaint Details
The complaint investigation addressed allegations of resident falls, staff not following diet restrictions, lack of activities, medication mismanagement, inadequate food service, lack of supervision resulting in residents wandering nude, and failure to execute emergency disaster plans. All allegations were found to be unfounded or unsubstantiated.
Findings
The investigation found all allegations to be either unfounded or unsubstantiated based on record reviews and interviews. No evidence was found to support claims of resident falls, diet noncompliance, lack of activities, medication mismanagement, inadequate food service, lack of supervision, or failure to execute emergency plans.
Report Facts
Facility Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Hripsime Makaryan | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: May 16, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations including questionable deaths, inadequate food service, untrained staff, medication regulation non-adherence, multiple pressure injuries, unmanaged incontinence, and lack of resident hygiene assistance.
Complaint Details
The complaint investigation was conducted following allegations of questionable deaths, inadequate food service, untrained staff, medication regulation violations, multiple pressure injuries, unmanaged incontinence, and lack of hygiene assistance. The findings determined the allegations were unfounded or unsubstantiated, leading to dismissal of the complaint.
Findings
The investigation found all allegations to be unfounded or unsubstantiated based on record reviews and interviews. Deaths were attributed to existing health conditions, food service met dietary needs, staff were trained, medication was properly managed, and there was insufficient evidence to prove violations regarding pressure injuries, incontinence management, and hygiene assistance.
Report Facts
Facility Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with during complaint investigation and named in report |
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: May 16, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not have a resident medically assessed in a timely manner after a fall and did not inform the resident's family of the fall.
Complaint Details
The complaint alleged failure to medically assess a resident timely after a fall and failure to inform the resident's family of the fall. Both allegations were found to be unfounded and the complaint was dismissed.
Findings
The investigation found the allegations to be unfounded. Medical care was provided timely and the resident's family was notified appropriately, leading to dismissal of the complaint.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during complaint investigation and informed of visit purpose. |
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: Nov 10, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of violation of general food service requirements and violation of personal rights.
Complaint Details
The complaint alleged violation of general food service requirements and violation of personal rights. The complaint was investigated and found to be unfounded.
Findings
The investigation found the allegations to be unfounded after reviewing facility files, interviewing staff and residents, and touring the facility. The complaint was dismissed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Hripsime Makaryan | Administrator | Facility administrator met during investigation |
Inspection Report
Follow-Up
Capacity: 100
Deficiencies: 0
Date: Nov 10, 2021
Visit Reason
The visit was conducted to follow up on an incident that occurred on 10/24/21 regarding resident R1.
Findings
The report documents a case management visit focused on incident follow-up. No specific findings or deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 100
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
The investigation was conducted in response to multiple complaints alleging resident unsupervised departure, inadequate staff supervision, understaffing, unkempt facility conditions, medication errors, and pest issues.
Complaint Details
The complaint investigation addressed allegations including resident left the facility unsupervised, staff not providing appropriate supervision, facility understaffing, unkempt conditions, resident receiving wrong medication, and pest control issues. All allegations were determined to be unsubstantiated or unfounded.
Findings
All allegations were found to be unsubstantiated or unfounded based on interviews, record reviews, and facility documentation. There was no preponderance of evidence to prove violations occurred.
Report Facts
Facility Capacity: 100
Resident Census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Hripsime Makaryan | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 100
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2021-02-17 alleging the facility did not provide records to a representative and did not communicate changes in a resident's medical condition to an authorized representative.
Complaint Details
The complaint alleged the facility did not provide records to a representative and did not communicate changes in a resident's medical condition to an authorized representative. The allegations were found unsubstantiated.
Findings
The investigation found the allegations to be unsubstantiated due to lack of preponderance of evidence. The Licensing Program Analyst met with the facility administrator and reviewed records and interviews to reach this conclusion.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
| Hripsime Makaryan | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 100
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2021-04-07 regarding inadequate staffing, failure to prevent inappropriate resident behavior, and lack of supervision resulting in resident AWOL.
Complaint Details
The complaint alleged inadequate staffing resulting in resident's diapering needs not being met, failure to prevent inappropriate resident behavior, and lack of supervision resulting in resident AWOL. The allegations were found unsubstantiated.
Findings
The investigation found the allegations unsubstantiated based on interviews and records review. No preponderance of evidence was found to prove the alleged violations occurred.
Report Facts
Capacity: 100
Census: 60
Inspection Report
Census: 60
Capacity: 100
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
Licensing Program Analyst conducted a Health & Safety visit as part of Case Management - Other to assess the facility's compliance and resident well-being.
Findings
Residents were observed to be well groomed and dressed with no immediate health and safety concerns. COVID-19 guidelines were in place and no deficiencies were cited during the visit.
Report Facts
Residents on hospice: 3
Residents receiving home health: 3
Staff present: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during the visit |
| Les Xiong | Licensing Program Analyst | Conducted the Health & Safety visit |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 100
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility had bed bugs and was not providing meals.
Complaint Details
The complaint investigation was conducted following allegations of bed bugs and lack of meal provision. The complaint was found to be unfounded based on inspections and interviews.
Findings
The investigation found no evidence of bed bugs after multiple pest control inspections and staff interviews. The allegation that meals were not provided was found to be incorrect as meals and snacks are provided daily by an outside vendor. The complaint was determined to be unfounded and dismissed.
Report Facts
Facility Capacity: 100
Resident Census: 62
Pest Control Inspections: 4
Rooms Inspected for Bedbugs: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lady Cabrera | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Hripsime Makaryan | Administrator | Facility administrator met during the investigation |
Inspection Report
Census: 65
Capacity: 100
Deficiencies: 0
Date: Oct 11, 2021
Visit Reason
An office meeting was conducted at Community Care Licensing to discuss the high frequency of service calls to Fresno PD related to residents with wandering tendencies and staff training.
Findings
The facility currently employs 7-9 staff including direct caregivers, medical technician, LVN, administrator, activities coordinator, housekeeper, and maintenance personnel. Food is prepared by an outside vendor. Additional documentation including staff schedule, food vendor contract, dietitian information, and dementia training materials were requested.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Present at the meeting and facility administrator |
| Anna Sahakyan | Assistant Administrator | Present at the meeting |
| Marina Isounts | CEO | Participated virtually in the meeting |
| Brenda White | Regional Manager | Present at the meeting |
| See Moua | Local Unit Manager | Present at the meeting |
| Les Xiong | Licensing Program Analyst | Conducted the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 100
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations including facility cleanliness, odor, staffing adequacy, medication administration, resident assistance, showering needs, and meal provision.
Complaint Details
The complaint investigation addressed allegations that the facility was dirty, malodorous, lacked adequate staffing, had unqualified staff administering medication, failed to assist residents with medication, did not meet showering needs, and did not provide meals to meet residents' needs. All allegations were found to be unsubstantiated or unfounded.
Findings
All allegations investigated during the complaint visit were found to be unsubstantiated or unfounded due to lack of sufficient evidence. The facility was found to have adequate staffing, proper medication administration, scheduled resident showering, and appropriate meal provision.
Report Facts
Facility Capacity: 100
Resident Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Hripsime Makaryan | Administrator | Facility administrator met during the investigation |
Inspection Report
Routine
Census: 65
Capacity: 100
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
Unannounced infection control inspection conducted as part of the required 1-year visit.
Findings
The facility was found compliant with infection control practices including symptom screening, PPE use, and visitation policies. No deficiencies were cited during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Named as Infection Control Lead and met during inspection. |
| Les Xiong | Licensing Program Analyst | Conducted the infection control inspection. |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including resident injuries and unmet hygienic needs.
Complaint Details
The complaint investigation addressed allegations that a resident sustained injuries while in care and that staff did not meet the resident's hygienic needs. These allegations were unsubstantiated. A separate allegation that a resident's medical device was damaged was found unfounded and dismissed.
Findings
The investigation found the allegations unsubstantiated due to lack of preponderance of evidence. Another complaint regarding a damaged medical device was found unfounded as the device was family-owned and naturally deteriorated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
| Hripsime Makaryan | Administrator | Facility administrator met with during the investigation. |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the complaint investigation. |
Inspection Report
Follow-Up
Census: 67
Capacity: 100
Deficiencies: 1
Date: Sep 16, 2021
Visit Reason
The visit was a follow-up on an incident that occurred on 2021-09-12 involving a resident who went AWOL from the facility.
Findings
The facility failed to provide adequate care and supervision to the resident, resulting in the resident leaving the building unassisted. This posed an immediate or substantial threat to the health, safety, or personal rights of residents in care.
Deficiencies (1)
HSC 1569.312(a): Facility did not provide care and supervision to resident R1, resulting in the resident going AWOL. Staff were unaware that the resident had left the building unassisted, posing an immediate threat to resident safety.
Report Facts
Plan of Correction Due Date: Oct 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with licensing evaluator during the visit and provided information about the incident and corrective actions |
| Les Xiong | Licensing Evaluator | Conducted the follow-up visit and documented findings |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 100
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility allowed smoking where oxygen is in use.
Complaint Details
The complaint alleging the facility allowed smoking where oxygen is in use was investigated and found to be unsubstantiated.
Findings
The investigation found the allegation to be unsubstantiated due to contradicting evidence and lack of preponderance of proof that the violation occurred.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit and delivered investigation findings. |
| Hripsime Makaryan | Administrator | Facility administrator met during the investigation. |
Inspection Report
Capacity: 100
Deficiencies: 0
Date: Sep 2, 2021
Visit Reason
The visit was a case management televisit conducted to follow up on an incident involving a resident who left the facility without authorization and returned later.
Findings
The administrator reported that a resident (R1) left the facility on September 1, 2021, and returned the same night. An Unusual Incident Report was generated and faxed to Licensing. Licensing requested additional documents related to the resident to be submitted by September 8, 2021.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met during televisit and provided information about the resident incident. |
| Les Xiong | Licensing Program Analyst (LPA) | Conducted the televisit case management. |
Inspection Report
Census: 62
Capacity: 100
Deficiencies: 0
Date: Jul 8, 2021
Visit Reason
Licensing Program Analyst conducted an unannounced Case Management visit regarding an incident report about an altercation between two residents.
Findings
Further information is required, but no deficiency was cited at this time. An exit interview was conducted and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during the visit. |
| Darius Williams | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Census: 62
Capacity: 100
Deficiencies: 0
Date: Jul 7, 2021
Visit Reason
The visit was an unannounced Health and Safety Case Management visit conducted to verify compliance with health and safety standards and review recent incidents at the facility.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst observed compliance with required postings, staff wearing face coverings, and availability of PPE and disinfecting products. Incidents involving residents were reviewed and appropriate reports were submitted.
Report Facts
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with Licensing Program Analyst during the visit and involved in incident reviews |
| Katie Brown | Licensing Program Analyst | Conducted the unannounced Health and Safety Case Management visit |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Date: May 7, 2021
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations that facility staff do not assist residents with medications, fail to meet residents' hygiene needs, leave residents in soiled bedding for extended periods, and fail to seek timely medical attention for residents.
Complaint Details
The complaint investigation was unsubstantiated. There was no information to indicate the alleged violations occurred.
Findings
The investigation found no evidence to substantiate the allegations. Interviews and record reviews determined that the allegations were unsubstantiated due to lack of preponderance of evidence.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hripsime Makaryan | Administrator | Met with during complaint investigation and mentioned in findings. |
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation. |
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