Routine inspection·December 17, 2025

On December 17, 2025, at 1:45 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Ali Johnson. LPA Kim spoke with Administrator (ADMIN) Khanh Do over the phone and explained the purpose of the visit. ADMIN Do stated that they could not make today’s visit and CG Johnson could sign on behalf of the facility. The facility is licensed to operate for six (6) nonambulatory residents and have a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, an office, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with CG Johnson. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were clean and operational. The water temperature measured at 126.8 degrees F to 129.0 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Evaluation Report Continues on LIC 809-C The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguisher that are charged and mounted in the kitchen and in the resident hallway across from resident room 1 and was last inspected on December 3, 2025. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The PUB475 poster at the facility was measured at 10.75” X 16.0” instead of the required 20” X 26”. The smoke detectors and carbon monoxide detectors were operable. First Aid kit had all the necessary elements. A working telephone (714274-9989) remains available. Certificate of Liability Insurance was effective from October 25, 2025, to October 25, 2026. At the time of the visit, the latest Emergency Drill log that was available at the facility stated that emergency drill was last conducted on May 20, 2025. LPA Kim conducted an audit of resident files (R1-R6), staff files (S1-S5), and medication and medication administration record. LPA observed the following on R1-R5’s reappraisal: R1’s latest reappraisal was conducted on July 24, 2024, R2’s latest reappraisal conducted was conducted on September 19, 2023, R3’s latest reappraisal conducted was on November 2, 2023, R4’s latest reappraisal was conducted on August 28, 2024, and R5’s latest reappraisal was conducted on November 21, 2024. LPA observed that following for staff Training hours for 2025: S1 completed 18 hours, S2 completed 18 hours, S3 completed 16 hours, and S4 completed 16 hours. LPA Kim conducted interviews with two (2) residents and one (1) staff. Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed water temperature from bathroom #1 measured at 129.0 degrees F, bathroom #2 measured at 126.8 degrees F, and bathroom #3 measured at 127.9 degrees F. LPA observed the following reappraisals not conducted within 12 months: R1’s reappraisal was dated on 7/24/2024, R2’s reappraisal was dated on 9/19/2023, R3’s reappraisal was dated on 11/2/2023, R4’s reappraisal was dated on 8/28/2024, and R5’s reappraisal was dated on 11/21/2024. LPA observed the last emergency drill was conducted on May 20, 2025. Evaluation Report Continues on LIC 809-C Technical violations were issued during the visit. LPA Kim observed Staff did not completed 20 hours of training: S1 completed 18 hours of training, S2 completed 18 hours of training, S3 completed 16 hours of training, and S4 completed 16 hours of training. LPA Kim observed PUB475 poster measured at 10.75” X 16.0” instead of the mandatory 20” X 26”. An exit interview was conducted, and a copy of this report, LIC811, LIC9102, and appeal rights were provided to Caregiver Ali Johnson.