Routine inspection·November 13, 2023

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Licensee Eunice Kim and explained the purpose of the visit. The facility is licensed for a capacity of 6 residents, ages 60 and over, of which 2 may be non-ambulatory. There is an approved hospice waiver for 6 residents. LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: Facility staff are using appropriate hand hygiene and wearing gloves while assisting residents when necessary. Staff continue to clean and disinfect daily and more often for high touched surfaces. Facility had submitted the Infection Control Plan. Operational Requirements: The facility accepts or retains residents with dementia. There are currently 4 residents diagnosed with dementia residing at the facility. 2 out of the 6 residents are non-ambulatory. Licensee has the sufficient amount for liability insurance that is required. Physical Plant & Environment Safety: The facility consists of a single story building with 4 resident bedrooms, 3 bathrooms, living room, dining space, kitchen, and attached garage. The backyard has area for gardening and relaxing. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. There are 2 operable carbon monoxide detectors and smoke detectors throughout the facility. The hot water temperature was measured within the required range of 105-120 degrees F. The fireplace is secured by a locked gate. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. The facility purchases meal plans from a food vendor for lunch and dinner. Staffing : The facility has sufficient staffing to meet the needs of the residents. Per administrator, there are backup staffing if needed. Personnel Records-Training : LPA reviewed 4 Staff files. The administrator's certificate expires on 5/15/24. Staff have fingerprint clearance and associated to the facility. All staff have current CPR and First Aid certificates. Licensee provides on-going training to staff. Resident Records-Incident Reports: LPA reviewed 6 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and Appraisal/Needs and Services Plan. The physician's report for resident #6 with dementia is not current. Resident Rights-Information : Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Incidental Medical & Dental: The medications are centrally stored. LPA reviewed 6 residents' medications and they are being given as prescribed by the physician's orders. Staff assist and transport residents to their doctor, dental, and specialist appointments. Residents with SHN : Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. A deficiency is issued on the LIC809D. Technical assistance are provided as well. An exit interview was held. A copy of this report along with appeal rights are given to the licensee.