Routine inspection·November 6, 2024

Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Samer Haddaddin arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by staff. LPAs met with Haeryun Cho, Administrator and explained the purpose of the inspection. The facility is two-story home. Per facility staff, residents do not go upstairs, as the facility owners reside upstairs. The first floor houses with four resident bedrooms, three resident bathrooms, kitchen, dining room, living room, attached 2-car garage and backyard. The second floor houses a bedroom, two bathrooms and a den. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed one resident's bed has full bed rails. AD could not provide a physician's order for the bed rails. A deficiency is being issued. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured 107.2, 108.3 and 109.2 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was purchased on 11/10/2023 according to the attached receipt. Smoke/Carbon Monoxide detector were tested and noted as operational. LPAs observed the drawer for the knives was unlocked. AD stated they could not find the key. A deficiency is being issued. Medication for each resident is kept locked in a cabinet in the dining area. LPAs observed exit gate to be unobstructed. LPAs reviewed six resident files and three staff files. LPAs also reviewed medication for three residents. Based on record review, LPAs determined, facility does not have health screenings for 2 staff members. A deficiency is being issued. Based on record review, LPAs determined the facility does not have a disaster drill log. A deficiency is being issued. Based on today's inspection, four citations are being issued. An exit interview was conducted and a copy of this report, deficiency pages, Component III presentation and appeal rights were provided to the facility.