Routine inspection·October 7, 2025

On October 7, 2025, at 9:30 AM, 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 met with Staff Dung Pham. The facility is licensed to operate for six (6) nonambulatory residents of which two (2) may be bedridden and have a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, two (2) outdoor covered seating areas, and an attached two car garage used as a staff lounge. LPA Kim toured inside and outside of the physical plant with Staff Pham. 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 found to be within Title 22 regulations and were clean and operational. The water temperature measured between 115.7 degrees F and 116.2 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C 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. 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 is stored in the cabinet next to the garage and emergency water and emergency supplies were stored in the garage. The facility has one (1) fire extinguisher that was charged and mounted in the kitchen. 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 smoke detectors and carbon monoxide detectors were operable. A working telephone (714-646-9825) remains available. Evidence of Liability insurance is valid from October 29, 2024, to October 29, 2025. The facility also provided the Evidence of Liability Insurance from October 29, 2025 to October 29, 2026. LPA Kim conducted an audit of five (5) resident files (R1-R5), staff files (S1-S8), and medication and medication administration record. LPA observed R1 is diagnosed with dementia and had their physician’s report dated May 28, 2024, and R2 is diagnosed with dementia and had their last physician’s report dated May 14, 2024. LPA observed R1 had their last appraisal needs and service plan dated July 1, 2024. LPA Kim conducted an interview with one (1) staff. Technical violations were assessed during the visit. R1 had their last appraisal needs and service plan dated July 1, 2024. R1 is diagnosed with dementia and had their physician’s report dated May 28, 2024, and R2 is diagnosed with dementia and had their last physician’s report dated May 14, 2024. An exit interview was conducted, and a copy of this report, LIC811, and LIC9102 were provided to Staff Dung Pham.