Routine inspection·March 18, 2026

On March 18, 2026, 12:15 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) Alfredo Ordona. LPA Kim spoke with Administrator (ADMIN) Ban Nguyen over the telephone and explained the purpose of the visit. ADMIN Nguyen stated they could not attend today’s visit and CG Ordona could sign in behalf of the facility.. The facility is licensed to operate for six (6) nonambulatory residents of which one (1) may be bedridden and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, outdoor covered patio in the backyard, and an attached two car garage. LPA Kim toured inside and outside of the physical plant. There were no obstructions in the facility. 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, and Resident Room 4. Bathrooms were found to be clean and operational. The water temperature measured between 122.0 degrees F to 125.0 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility. LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, 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 both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and mounted on the wall next to the entrance. It was last serviced on December 3, 2024. 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 except the resident hallway was missing a smoke detector and the shared resident room next to the living area did not have a battery in the detector. The facility did not have a battery to place one in the smoke detector missing the battery. A working telephone (714-916-0629) remains available. Last emergency drill was conducted on March 15, 2026 and is conducted monthly. First aid kit is maintained and contains all the necessary elements. Evidence of Liability Insurance is effective March 22, 2025, and expires March 22, 2026. The facility also provided the insurance that is effective March 22, 2026, and expires on March 22, 2027. LPA Kim conducted an audit of resident files (R1-R4), staff files (S1-S6), and medication and medication administration record. R1’s last appraisal needs and service plan was on January 13, 2023, R2’s last appraisal needs and service plan was on January 13, 2023, and R3’s pre-appraisal was not completed. LPA Kim conducted interviews with one resident and two staff. Deficiencies were cited during this visit per Title 22 Division 6 Chapter 8. LPA observed resident bathrooms hot water temperature measured between 122.0 degrees F to 125.0 degrees F. During the visit, the facility adjusted the water temperature and LPA Kim observed the resident bathrooms hot water temperature measured between 116.0 Degrees F to 118.0 Degrees F. LPA observed smoke detectors were missing in the hallway and the shared resident room next to the living area. LPA observe R1’s and R2’s last appraisal needs and service plan was from January 13, 2023 and R3’s pre-appraisal was not completed. An exit interview was conducted, and a copy of this report, LIC809D, LIC421FC, and appeal rights were provided to Caregiver Alfredo Ordona.