Routine inspection·February 18, 2025

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator David Kim and explained the purpose for today’s visit. The facility is licensed to serve 1 Ambulatory Resident and 12 Non-Ambulatory Residents ages 60 and over (of which 6 may be bedridden). Facility has a hospice waiver for 6, there are currently 4 residents using hospice services. The Facility is a single story building located in Downey, CA. A tour of the facility included: 11 resident bedrooms, 7 bathrooms, living room, dining room, tv room, kitchen, laundry room, two (2) shaded patio areas, detached garage and tool sheds used for storage and emergency food supply. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance and maintain the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees. There is a shaded patio/garden areas for residents. Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.(Continued on LIC809-C) Personnel Records-Training : Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed, 2 staff were missing their first-aid training (prior to end of visit both staff were able to show completion of training done on 2/18/25) citation issued as both staff had expired first-aid certificates from 9/2024 and 12/2024 (details found on LIC800-D). Administrator David Kim certificate expires on 6/21/2025. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 5 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted on each floor/section: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit will be cited on the 809D. Exit interview held, a copy of the report and appeal rights were provided to Administrator David Kim.