Routine inspection·October 8, 2024

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 10/8/24. LPA arrived unannounced and explained the reason of the visit to licensee/administrator, Eunice Kim. The facility is licensed for 6 residents ages 60 and over. There may be (4) ambulatory and (2) non-ambulatory residents. The non-ambulatory is approved for room #1 only. There is a hospice waiver approved for 6 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility. The single story home consists of 4 resident bedrooms, 2 bathrooms, living room, dining room, kitchen, and attached garage. There is a swimming pool in the backyard and is secured by a fence. The fireplace is adequately screened with a lock. There are no items obstructing the walkways. There are smoke and carbon monoxide combo detectors located in each room and hallway. The bedrooms have the required furniture and storage space. There is sufficient lighting throughout the facility. Facility has sufficient food supplies of perishable and non-perishable. The hot water temperature was measured within the required range of 105-120 degrees F. There are surveillance cameras located in the common areas. Medications are centrally stored and locked in a cabinet located in the dining room. LPA reviewed medications for 2 residents and no discrepancies were found. Both residents' files were reviewed and Resident #2's physician's report was not current. LPA reviewed 3 personnel files. The administrator's certificate expires on 5/15/24 but was verified that the renewal documents were submitted. Staff have current CPR & First Aid certificates, health assessment and TB results, and on-going training. Facility has the updated LIC610E Emergency Disaster Plan with the emergency procedures posted. Licensee is conducting emergency disaster drills with staff. The facility has appropriate liability insurance covering the $1,000,000 per occurrence and $3,000,000 in annual aggregate. LPA issued a deficiency on the LIC809D form. A technical violation was given. An exit interview was held and a copy of this report was given to the administrator.