Routine inspection·January 9, 2026

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 01/09/2026 and was greeted by Caregiver Bokki Jung. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a residential street and is a single-story dwelling. Video surveillance was observed in common areas. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: During tour of facility, LPA Ramirez observed green rubbing alcohol on a nightstand next to R3's bed. Per caregiver S2, R3 uses rubbing alcohol for personal grooming. During resident record review, R3's physician documented that R3 may not have items of personal grooming accessible to them for safety reasons. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms and two (2) resident bathrooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip coating in showers. LPA Ramirez observed seated shower chairs in bathroom. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Six (6) out of the six (6) residents in care speak and read in another language (Korean). Administrator Kim will post a Complaint Poster (PUB 475) in language spoken by residents. see 809-C Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. No proof of documented emergency drills was provided when requested. Residents with Special Needs : No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. During facility tour, LPA Ramirez observed six (6) out of six (6) resident beds had full bed rails. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cart and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Hyo Sook Kim with an expiration date of 04/18/2027 was observed. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files were made available upon request. Personnel records for S2 & S4 including job application were left blank. During personnel record review, S2 & S4 did not have documentation of First Aid/CPR training in their files. S4's documentation of training dates and hours were left blank. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non ambulatory residents over the age of 59 years old, of which three (3) may be bedridden. This facility may retain no more than six (6) hospice residents. There was one (1) resident on hospice during time of inspection. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Five (5) deficiencies were observed during this visit. Exit interview conducted. A copy of this report, 809-D, LIC 9102, and appeals rights was provided.