Routine inspection·November 6, 2025

On 11/06/2025 at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Dwight Holt and explained the purpose of the visit. Dwight phoned the Licensee/Administrator, Jinyoung Rhu, to inform. The facility’s fire clearance was approved for six (6) non-ambulatory. In which one (1) may be bedridden. Hospice waiver approved for four (4) residents. Administrator certificate # #7004049740 Expires 05/17/2026. Jinyoung Rhu was not available during visit. Therefore gave authorization for Staff, Kyongmin Yu to sign the report. LPA toured facility with Kyongmin including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which all 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 70 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 bathrooms was measured at 116.3 and 116.2 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. LIC809-C Continued... LIC809-C (page 2) Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/04/2025. Emergency Disaster Plan was last posted on 09/02/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/18/2025. LPA reviewed five (5) residents records. LPA reviewed six (6) staff records and all staff 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 11/13/2025: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed 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.