Pre-licensing visit·July 8, 2022

Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an announced pre-licensing visit with Area Director Tony Duarte and Facility Administrator (AD) Jennifer Kum. LPAs observed the Administrator's Certificate for Jennifer Kum, which expires on 4/21/24. LPAs De Perio and Marin toured the facility with AD Kum and observed the following: Structure: Facility is a single level structure . On May 26, 2022, The Orange County Fire Authority granted a fire clearance for a capacity of four of which four may be non-ambulatory. (Note: Facility is currently licensed under California Department of Public Health as a Intermediate Care Facility with a capacity of 6). There are two bathrooms, and four bedrooms, and the garage is utilized as a common area as an office, staff area and activity room. No bodies of water were observed. There is also a locked shed in the backyard that is used to store tools. Resident Bedrooms: All four bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free. Bathrooms: The restrooms were observed to be in good repair, toilet was operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 112.8 degrees Fahrenheit. Linens and Hygiene Supplies: Adequate supply of linens is stored in the hallway. Continued on Page 2. Posters, Emergency Phone Numbers, Exit Plan: LPAs observed the COVID-19 precautionary signs posted, along with the PUB475 "See Something, Say Something" poster. Emergency plan is posted in the staff office. Food Service and Menu: Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Facility had back-up emergency food and water supply, also located in the staff office. Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide were tested and operational. Fire Extinguisher: Fully charged, mounted, and located in the kitchen. Appliances: Stove is a four-burner induction stove, and there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the garage, along with extra refrigerator and freezer. Toxins: Located and stored in the garage and is inaccessible to residents. Medications, First-Aid Kit and Manual: LPAs observed that First Aid Kit had all the required components. Medications were locked in a cabinet locked in the staff office. Resident and Staff Files: Records were kept in a locked cabinet located in the staff office. Recreational Activities: The facility has activities that commensurate with plan of operation. Continued on Page 3. LPAs De Perio and Marin verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Kum and Area Director Duarte. LPAs discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Based on this visit, the following updates are needed: Hand-washing signs posted in restrooms Ombudsman poster posted Auditory exit alarms Both backyard gates to be self-latching and self-closing Stabilize outside wooden railing AD Kum and Area Director Duarte agreed to complete the following updates by 7/15/22. LPA Marin reviewed the Component III with AD Kum and Area Director Duarte. LPA De Perio conducted an exit interview with AD Kum and Area Director Duarte and a copy of this report was provided to the facility.