Inspection Report
Annual Inspection
Census: 85
Capacity: 102
Deficiencies: 1
Sep 23, 2025
Visit Reason
The visit was an unannounced continuation of the required annual case management inspection to review compliance with licensing requirements.
Findings
The inspection found that resident and personnel records were in order; however, medication records for four residents were inaccurately maintained, with medications not recorded or having incorrect discard dates on the centrally stored medication record.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Four out of four residents' medications reviewed revealed inaccurate medication record keeping on the centrally stored medication record log. | Type B |
Report Facts
Residents' medication records reviewed: 4
Resident files reviewed: 8
Personnel files reviewed: 8
Plan of Correction due date: Sep 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lilit Chaparyan | Executive Director | Met with during inspection and named in report |
| Catalina Cantreas | Resident Care Coordinator | Reviewed medication records with Licensing Program Analyst |
| Zabel Chochian | Licensing Program Analyst | Conducted the inspection and signed the report |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 85
Capacity: 102
Deficiencies: 0
Apr 16, 2025
Visit Reason
The inspection was an unannounced required annual visit conducted by Licensing Program Analyst Zabel Chochian to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with health and safety regulations with no health and safety issues observed. Resident rooms and common areas were clean and properly furnished, medications were stored and dispensed as prescribed, and infection control policies were adequate. Some records review was deferred to a later date due to time constraints.
Report Facts
Rooms toured: 8
Residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lilit Chaparyan | Executive Director | Met with Licensing Program Analyst during inspection |
| Zabel Chochian | Licensing Program Analyst | Conducted the annual inspection |
| Martin | Maintenance Director | Met with Licensing Program Analyst regarding fire and safety systems |
| Desaree Perera | Licensing Program Manager | Named in report signature section |
Inspection Report
Original Licensing
Census: 78
Capacity: 102
Deficiencies: 0
Apr 9, 2024
Visit Reason
A pre-licensing visit was conducted for a Change of Ownership Application (CHOW) for the facility currently operating with an existing license and residents in care.
Findings
The facility was found to be in compliance with no corrections required at this time. The facility was observed to be clean, properly furnished, with adequate infection control measures, proper medication storage, and all records in order.
Report Facts
Non-ambulatory capacity: 94
Bedridden capacity: 8
Resident records reviewed: 6
Personnel records reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lilit Chaparyan | Executive Director | Met with during inspection and mentioned in relation to facility operations |
| Brian Balisi | Licensing Program Analyst | Conducted the pre-licensing visit and signed the report |
| Valeria Conway | Licensing Program Analyst | Conducted the pre-licensing visit |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Beatriz Martinez | Health Services Director | Stated to sign in place of Executive Director during the visit |
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