Routine inspection·June 5, 2025

On 06/05/25 at 8:36 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. Upon arrival it was noted that there was no one at the facility. LPA Lee called licensee Chris Faamausili to informed that LPA Lee is at the facility to conduct an annual inspection. Licensee stated that there are no residents currently residing in the home but will send a staff to let LPA Lee enter the home and conduct the annual inspection. Approximately 30 later Assistant Administrator Shay Swogger arrived at the facility and assisted with the inspection. The census is 0. This facility is licensed to served 6 non-ambulatory residents in room 1, 2, and 3. The facility second floor and detached garage are not for resident’s use. This facility also holds a hospice waiver for 6. LPA Lee along with assistant administrator Shay inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 110.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the common area and was last serviced on 12/18/24. Continued LIC 809-C LPA Lee observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat was observed at 71 degrees Fahrenheit. LPA Lee observed toxins located in storage room and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinets and inaccessible to residents. The first aid kit was checked and contained the required components. LPA Lee requested staff files for review. LPA Lee reviewed 2 out of 2 staff files and they were complete. LPA Lee reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents was provided to LPA Lee during today's visit: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Shay Swogger, and a copy of these LIC 809 reports were provided to the facility.