Routine inspection·September 9, 2021

On 9/9/2021 Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted an unannounced site visit for the annual inspection. LPAs met with Jung Hyun Kim (Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. 6 ambulatory of which 3 may be non-ambulatory. Hospice waiver for 2. LPAs observed COVID19 informational and symptom posters by front door and throughout facility. There is hand sanitizer available throughout facility. The facility is located in a residential area. A tour of the single-story facility includes: Living room, den, garage/laundry/Storage, 4 bedrooms, 3 bathrooms, tv room, kitchen, dining area. The following was observed: Facility is operating within capacity and not beyond any conditions and limitation on the license. No pools and bodies of water, no firearms. Comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature measures at 109.4 degrees F in bathroom #1. There are presence of grab bars for each toilet, bathtub and shower used by residents. Bathtub or shower have non-skid mats or strips. The total daily diet is of the quality and in the quantity necessary to meet the resident’s needs. Minimum of one week supply of nonperishable foods and 2 days of perishable foods observed. Perishable foods and beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. The facility has sufficient staff to provide the services needed to meet resident needs. Staff in sufficient numbers to meet the needs of all dementia residents and to escort residents who leave the facility. Items that could constitute a danger is stored inaccessible to dementia residents. Staff assisting residents with ADLs has required training. Staff has Criminal Record Clearance. Resident have a medical assessment, signed by a physician within the last year. Facility has a disaster and mass casualty plan in writing and be readily available. No persons have a prohibited health conditions. Centrally stored medicines is kept in a safe and locked place. Carbon Monoxide detector and smoke alarm were observed to be functioning properly. LPAs observed fire extinguisher fully charged. CONTINUED 809-C The following deficiencies were observed at time of visit: LPAs observed both outside gates with a lock that can only be unlocked with a numerical code LPAs observed medication discrepancies for R1, R1 is being administered Vitamin D without a prescription, Vitamin C without a prescription label, and Probiotic without a prescription label. LPAs observed medication discrepancies for R2, R2 Nattokinase 2,000 FUS without a label and C-1000 Antioxidant without a label. Exit interview conducted, a copy of report and appeal rights provided.