Routine inspection·November 4, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Hyo Seon Kwak, Caregiver and explained the purpose of today's visit. Shortly after, Eunice Kim, Administrator and John Kim, RN arrived and assisted LPA. The facility is approved for age range 60 and over, approved for capacity of (4) ambulatory and (2) non ambulatory. Facility has approved hospice waiver for (6) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices are maintained and staff are adhering to infection control requirements. The use of Infection Control procedures are reviewed/updated. Staff ensure that residents are regularly observed for physical, mental, emotional and social functioning changes. Staff ensure that appropriate assistance is provided and such changes are documented and brought to the attention of the residents' physician. Operational Requirements: The Infection Control Plan has been added to the Plan. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid, expires on 07/07/2026. Physical Plant & Environment Safety: This facility is a single story home consists of kitchen, dining room, living room, (4) resident bedrooms, (1) office, (3) bathrooms, attached garage, and a shaded patio with seating. Currently, there are (6) residents living in the home. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. L P A observed a fire extinguisher near the dining area purchased on 09/08/2025. Knives, cleaning solutions, and disinfectants are lo cked and inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. LPA observed a shed in the backyard being used as a resting area/bedroom for staff. There are surveillance cameras in the common areas. *****Refer to LIC 809C for the continuation of this report.***** Staffing: A total of five (5) staff members including the night staff and Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Current Administrator's certificate is pending, expires on 05/15/2026. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (5) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current. Dementia care is part of training for direct care staff. Resident Rights-Information: Resident rights are posted. Facility provides internet service and phone to the residents. Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. There is one (1) resident with special diet residing at this facility. Incidental Medical Services: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. Administrator did not indicate the time in which residents' medications were administered in a given day. Resident Records-Incident Reports: LPA reviewed (5) resident files. Residents files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan which is posted. Facility conducts emergency drill (earthquake & fire) at least quarterly. Last fire and earthquake drills were conducted on 10/01/2025. Residents with SHN: Facility accepts and retains residents with dementia . Facility has sufficient space to permit residents with dementia to wander freely and safely. Administrator ensures that there is at least one night staff person awake and on duty for night supervision of residents with dementia. LPA observed (3) residents with bed rails, however, only (2) residents have physician's authorization. One of the residents, (R5) is not receiving hospice care has full bed rail that is prohibited. Additionally, R5 does not have a physician's order on file. Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy this report was provided to Administrator, Eunice Kim.