Routine inspection·August 26, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Eunmi Kong and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory elderly residents age 59 and over. Approved Hospice Waiver for 2. The facility is in a residential area and consist of a two-story home and consist of (4) resident bedrooms,(3) bathrooms (1) visitor's bathroom, kitchen, activity area, family hall with a prayer room, foyer, and office, dining room, laundry room located inside the kitchen area, front porch, and a backyard. Second floor is inaccessible to the residents. LPA Flores conducted a tour with Eunmi Kong and observed the following: Facility is in good repair indoor and outdoor. Each common area is clean with furniture in good repair. Each resident bedroom has the required furniture, bedding supplies, and sufficient lighting. Bathrooms are in good repair and water temperature was tested at 111.5 degrees F. Kitchen was observed clean with sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Sharps were observed lock in a drawer. Cleaning supplies are inaccessible to the residents. Carbon Monoxide/Smoke detectors were observed throughout the facility in working condition. No large bodies of water were observed. Ramps and passage ways are clear. Backyard has a covered/shaded seating area. LPA reviewed 3 resident files and medication and 3 staff files. Staff has been provided 20 hours of yearly training. However, training on postural support, hospice, health services and restricted conditions was not provided to staff. There are no residents on hospice or home health care at this time. Facility does not have a copy of Infection Control Plan at the time of the visit. However, they are following infection control prevention. (CONTINUED ON LIC 809C) Emergency Disaster plan was available for review. However, pages 4 to 9 were not filled out. Last emergency drill was conducted on 5/1/23 per administrator. Administrator certificate was observed for Eunmi Kong #7035628740 exp. date: 11/10/25. Deficiency was noted on LIC 809D and technical violations and assistance were provided. Exit interview was conducted with Eunmi Kong and a copy of this report, LIC 809D, and appeal rights were provided.