Correction check·June 5, 2025

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 05/23/2025 during the required annual inspection. LPA was greeted and granted entry by staff and discussed the purpose of the inspection. Administrator (AD) Tin Le arrived shortly to assist with the inspection. LPA toured the facility to check if the deficiencies had been corrected with staff. LPA observed corrections and reviewed documents. The following deficiencies were corrected: Type A deficiencies: CCR 87309(a) - cleaning supplies were locked away during inspection on 05/23/2025 CCR 87412(c) - Staff 3 (S3) completed new hire training on 06/04/2025 using a third party service HSC 1569.625(b)(2) - Staff 1 (S1) completed annual training on 05/30/2025 using a third party service CCR 87465(a)(6) - In service medication administration training was provided by hospice nurse CCR 87465(h)(2) - Medication cabinet lock was replaced and now functional CCR 87608(a)(5)(B) - Full bed rails were removed for resident 2 and replaced with half rails with orders CCR 87207 - Licensee signed a statement of acknowledgement with regards to falsifying records CCR 87405(a) - Licensee has designated a qualified back up Administrator for the facility Type B deficiencies: CCR 87507(l) - Personal Rights document signed and placed in resident 3's file. HSC 1569.695(a)(2) - Emergency water was purchased for facility. HSC 1569.695(c) - Disaster drills were completed on 05/30/2025 Continued on LIC809-C dated 06/06/2025 LPA reviewed Type A deficiency CCR 87305(a) and at this time, AD has not obtained a building permit for the room built into the garage, thus not correcting the deficiency by the Plan of Correction (POC) due date of 5/24/2025. LPA reviewed Type A deficiency CCR 87465(a)(5)(A) and at this time, one medication which requires the use of a nebulizer is not being administered per physician order for Resident 1 (R1) , thus not correcting the deficiency by the POC due date of 5/24/2025. Based on LPA's observation and record review on today's visit, the Plan of Corrections have not been fully completed by the POC due date. Civil penalties for failure to correct deficiencies are being assessed. See LIC421FCs An exit interview was conducted with Administrator Tin Le and a copy of this report was provided to the facility representative.