Routine inspection·October 27, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA were met by Hyo Seon Kwak, Caregiver and explained the purpose of the visit. Shortly after, Administrator Eunice Kim arrived and assisted LPA with the inspection. The facility is approved to serve elderly residents, age 60 and over, (4) ambulatory and (2) non-ambulatory, non ambulatory in room #1 only. Hospice waiver approved 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 and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as hand soap and toilet paper. Operational Requirements: Fire Drill is conducted monthly and the last drill was conducted in July 2025. Facility has working signal systems in exit points. Facility maintains liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate and expires on 10/21/2026. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (2) bathrooms, living room, dining room, kitchen, and attached garage. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed cameras in the common areas with no audio. The fireplace is adequately screened with a lock. Backyard was inspected and has a shaded area and sitting area.There is a swimming pool in the backyard and is secured by a fence. There is (1) fire extinguisher in the facility which was purchased o n 09/08/2025. Smoke alarms and carbon monoxide were tested and operable. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. Hot water readings were 111.0 deg F in bathroom #1 and 108.2 deg F in bathroom #2. ****REPORT CONTINUED ON LIC809-C***** Staffing: A total of (5) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility and were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Current Administrator's certificate is pending, expires on 05/15/2026. Staff have current CPR & First Aid certificates, health assessment and TB results, and on-going trainin g. Resident Rights-Information: Resident personal rights are posted. Visiting policy is posted at a location that is visible and accessible to residents and families. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. The facility provides sufficient space to accommodate both indoor and outdoor activities. Food Service: The kitchen was inspected and did not have sufficient supply of 2 day perishable & 7 day non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas. Staff provide modified diet to (1) resident as prescribed by a physician. Incidental Medical Services : All (5) residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications were stored in a locked cabinet and inaccessible to residents. Resident Records-Incident Reports: All (5) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a monthly basis. Last fire drill was conducted on October 1, 2025. Residents with SHN: (6) residents are under hospice care. Physician orders for use of half bed rails were reviewed in (3) residents files. No bedridden residents. No deficiencies cited and Technical Assistance issued. Exit interview and a copy of this report was provided to the Administrator, Eunice Kim