Routine inspection·April 15, 2025

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Jesus Benbinen and explained the reason for the visit. Administrator (Admin) Clara Han arrived on premise to assist with the inspection approximately 9am. Administrator Han has a valid administrator's certificate expiring on February 10, 2027. The facility is a single story structure and is licensed to operate for six non-ambulatory and has a hospice waiver for four residents. LPA observed two caregivers providing care to six residents. During the tour of the physical plant, LPA observed six resident bedrooms and two resident bathrooms. There is a private staff bedroom occupied by two staff and one private staff bathroom. Resident bedrooms had all required furnishings. Bathrooms were found to be in compliance, clean, and operational except the private bathroom of Bedroom #3 evidenced by an unclean sink and shower. The private bathroom is not in use which was confirmed by Resident #5 (R5). The hot water temperature measured at 112.2 and 111.7 degrees Fahrenheit. All common areas were inspected including the attached two car garage which doubled up as an office and laundry area. LPA observed sufficient emergency food and water. Emergency supplies were unavailable. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. LPA observed sufficient seating and shading. The outdoor shed was secured and inaccessible. The outdoor fountain did not have water. The fire extinguisher was mounted, charged, and serviced on April 4, 2025. The auditory devices and smoke/carbon monoxide detectors were tested and operational in all areas. Emergency evacuation drills are not conducted quarterly. The first aid kit contains all necessary elements. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the incorrect size of 8.5"x11." LPA conducted a file review of all residents and two staff. No discrepancies noted. Medications were audited for three of six residents. No discrepancies noted. Interviews were also conducted. The following items were addressed during the exit interview: to conduct quarterly emergency disaster drills, to obtain the emergency supplies as indicated on the Emergency Disaster Plan (LIC610E), to increase the size of the Complaint Poster (PUB 475) to 20"x26," and to deep clean the private bathroom of R5. Based on the observations made during today's visit, no deficiencies are being cited. Advisory Notes (LIC9102s) are being issued. An exit interview was conducted Administrator Clara Han, and a copy of this report including LIC811 and the LIC9102s were provided at the end of the visit.