Routine inspection·September 9, 2024

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Phyllis Lee - Assistant Administrator and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60 and over (dementia approved), with a Hospice waiver for 2. There are no Residents with Hospice services at the moment. The facility is a single-story home located in Lakewood, Ca. A tour of the facility includes: 4 resident bedrooms, 1 bathroom, living room, kitchen, laundry area, front yard, and backyard. There is a separate area for staff that includes bedroom, living room, there is also 1 staff bedroom and Staff office area with surplus of canned foods/refrigerated food. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: Staff are cleaning and disinfecting throughout the day and have an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. (continued on LIC809-C) 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. Personnel Records-Training : Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Seong Soo Han maintains a valid Administrator Certificate that expires on 3/2/2026. Resident Records-Incident Reports: Resident files are kept in a secure location (within staff office area) 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 4 Resident Files, there will be a citation as 1 out of 4 files reviewed was missing an updated needs and service plan, last updated plan was when resident was admitted in 2017, details will be found in the LIC809-D Residents Rights-Information: Residents are provided with telephone and internet at the facility. Planned Activities: Facility provides a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. 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 in a closet and are in their original containers. LPA reviewed 6 residents’ medications and there were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The facility did not have record of the last Fire/Earthquake/Emergency Disaster Drill, citation will be issued and details will be found on LIC809-D. Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. Residents with half-bed rails had a prescription for them within their file. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit will be detailed in the LIC809-D. Exit interview held and a copy of the report and appeal rights were provided to Phyllis Lee.