Routine inspection·July 21, 2025

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Annual Required visit to the above facility. LPA was met by Eunmi Kong , Administrator and the purpose of today’s visit was explained. The facility is licensed to serve (6) non-ambulatory residents ages 60 and above and hospice waiver for (2). There are currently (0) residents on hospice. There are currently (4) residents in the facility . LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted an a current Infection Control Plan. 2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 2) PHYSICAL PLANT The facility consists of 4 resident bedrooms, 4 bathrooms (1 bathroom is for visitor use), kitchen, family hall with a prayer room and recreation area, dining room, laundry room located inside the kitchen area. Adequate linen and personal hygiene supplies were observed. Medications were centrally stored, locked and inaccessible to residents in care. Auditory device alarms are operational. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. The outdoor area has a shaped area and seating. Water temperature was tested between 119.1 – 129.3 degrees F which is not within the required range of 105.0 -120.0 degrees F. (continued on 9099C) (continued from 809) 4. Staffing: The facility has sufficient staff, and the night supervision staff have current CPR/first aid certification. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All staff have required ongoing training. Administrator Eunmi Kong Certificate expires 11/10/2025 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster are posted at facility. Visiting hours are included in the admission agreement. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and did have sufficient supply of 2-day perishable & 7-day non-perishable food. The kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. Pesticides and cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents. 10. Incidental Medical and Dental: Medication is centrally stored and locked in the medication cabinet near the kitchen. Four (4) centrally stored resident medications were reviewed, which contained 30-day supply of medications. All medications are administered according to physician’s orders. Two (2) residents PRN medications did not have labels. Disaster preparedness: The last fire drill was conducted on 06/16/2025. The facility has an Emergency Disaster Plan posted at the facility. 12. Resident with Special Health Needs: No residents receive home health services. No residents are currently on postural support. Individual Service Plans and Appraisals are on file. Deficiency observed during today’s visit. Technical advisory issued. An exit interview was held. A copy of this report, and appeal rights were provided.