Routine inspection·December 5, 2024

On 12/05/2024 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Jinyoung Rhu and explained the purpose of the visit. The facility’s fire clearance was approved for capacity six (6) all non-ambulatory, of which one (1) may be bedridden. Hospice waiver approved for four (4) residents. Administrator Certificate # 7004049740 expired 05/17/2026. LPA toured facility with Jinyoung including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which five (5) bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 07/19/2024. Emergency Disaster Plan was last posted on 10/03/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/20/2024. LIC809-C Continued... LIC809-C (Page 2) LPA reviewed four (4) residents records. LPA reviewed three (3) staff records and all three (3) have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/12/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Current Administrator’s Certificate - Reviewed No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.