Routine inspection·February 3, 2025

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Monica Kim and the purpose of the visit was explained. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed Physical Plant/Environment Safety: The facility is a single-story home: Total of (9) bedrooms of which #1-#6 is for residents only and #7-#9 are staff rooms and office spaces, (3) bathrooms, dining room, (2) living rooms, backyard with locked detached garage, and a laundry area. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Water temperature readings measured within title 22 regulations. Operational Requirements: A current Plan of Operation observed. Dementia Care Plan Observed A fire clearance for 6 residents of which (6) may be non ambulatory and up to three (3) bedridden Hospice care waiver approved for up to six (6) residents. Facility has an active liability insurance. Copy was collected and reviewed Personnel Records - Staff Training: Administrator on file is current. Administrator certificate is currently active Five (5) staff files were reviewed. Required documents observed for files reviewed. Staffing: Sufficient staff observed during visit Continued on LIC 809-C Resident Records - Incident Reports: A total of six (6) resident files were reviewed. Required documents observed Resident Rights - Information Required postings observed Facility provides internet services to residents in care Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities supply observed Incident Medical and Dental: Emergency transportation available First Aid Kid observed (5) of (6) Resident medications reviewed. (1) Resident has their medication handled by family. Disaster Preparedness: Emergency and Disaster Plan observed Emergency drills conducted per title 22 guidelines Residents with Special Health Needs: Needs and Services Plans are on file for all residents. Currently (2) residents receiving home health services. Written agreement of services observed. (0) Residents are on hospice. Inspection Tool was completed and per Title 22 no deficiencies are being cited on todays visit. Exit interview conducted. Copy of this report was provided.