Routine inspection·July 24, 2025

Licensing Program Analyst(LPA) Sakinah Madyun and Out Of Class-Licensing Program Manager(LPM) Mary Flores conducted an annual visit. LPA and LPM met with Xia QinFen and explained the reason for the visit. This facility is licensed to serve (49) Non- Ambulatory resident's age 60 and above. The facility may retain one bedridden resident in room#11. Hospice waiver approved for five (5) resident's. The facility consists of a single level building with (35) resident bedrooms, with private bathrooms, an activity room, chapel, laundry room, common shower area, facility kitchen and dining room area. There are (2) offices, a medication room, and a courtyard. LPA and LPM toured the facility with Xia QinFen and observed the following: Infection Control : Facility does not have a copy of a Infection Control Plan. All staff have a TB clearance. Operational Requirements: Facility maintains a plan of operation and a fire clearance. Facility is operating within the limitations of their license. They have (5) resident's under hospice. A current liability insurance was observed and a copy was obtained. Physical Plant/Environmental Safety: During facility's tour LPA and LPM observed all common areas in good repair. A total of (5) random residents' rooms were observed. Each room was furnished, with sufficient lighting, and bedding supplies, with the exception of bedroom #29 bathroom's light. Water temperature was tested in each resident's bathroom and tested between 110.0 - 122.2 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and skid mats. (CONTINUED ON LIC 809C) Dining room has a covered fireplace. LPA and LPM observed a can of WD40 above the fire extinguisher by the front entrance and (2) bottles of cockroach spray in the laundry area which is accessible to residents. Resident Rights/Information: License , Ombudsman, personal rights posters were posted in entrance of facility hallway. The Let us Know (PUB 475) was not observed. Food Services: LPA and LPM toured the commercial kitchen and observed food supplies for at least (2) days of perishables and (7) days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. Currently there are no residents with modified diets. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication room. LPA and LPM reviewed medication for (5) resident's. No residents have taken PRN medication in the last month. Resident Records/Incident Reports: LPA and LPM reviewed (5) resident's files, each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal. Resident #2 file was observed with Physician's Report dated 8/1/23 and Appraisal dated 7/5/23. Resident #3 file was observed missing an Appraisal. Interviews were attempted to be conducted with (4) resident's. Disaster Preparedness: LPA and LPM reviewed Emergency Disaster Plan LIC 610E (10/03) which is not the current revision. Emergency Drills are conducted quarterly, last Emergency Drill was conducted on 2/21/25. Facility has fire extinguishers and fire sprinkler system throughout as well. Staffing: Administrator certificate was reviewed for Kun Hu #70000337400 exp. date: 10/10/2025. CPR/First Aid training was observed for (5) staff files. Call buttons were tested for (3) resident's and they were responded to immediately. Personnel Records/Staff Training: LPA and LPM reviewed (5) staff files. Files include; TB clearance, background clearance, personnel record, and training. Health screenings were not observed for all (5) staff. Interviews were conducted with (3) available staff. Planned Activities: LPA and LPM observed activity calendar and staff communicated what additional activities are held at the facility. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Kun Hu and Pinshi Liu a copy of this report LIC 809D and Appeal Rights provided.