Post-licensing visit·October 14, 2025

On 10/14/2025, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee arrived met with administrator Tevita Kaloulasulasu and explained the purpose of the visit. Administrator assisted with today’s visit. There are currently six (6) residents living at the facility. LPA conducted a tour of the physical plant, both inside and outside, alongside Administrator Kaloulasulasu to assess any health and safety concerns. LPA inspected the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garge and outdoor courtyards to ensure compliance with Title 22 regulations. The facility was observed to be clean, free of odors, and in good repair. Resident bedrooms were appropriately furnished, with adequate bedding and lighting. The hot water temperature was measured at 110.6°F. The indoor temperature was 73°F, which falls within the required range of 68°F to 85°F. LPA observed the facility maintains at least one week’s supply of nonperishable food and two days’ supply of perishable food. The centrally stored medication area was locked and inaccessible to residents. Fire extinguishers and first aid kits were up to date. The fire extinguisher was last service on 11/27/2024. Smoke and carbon monoxide detectors were present and in good working conditions. LPA reviewed files for all six (6) residents and two (2) staff members. All records were complete and contained the required documentation. Staff records confirmed that all individuals requiring caregiver background checks were fingerprint cleared and properly associated with the facility. During today’s visit, LPA was informed by Staff #1 (S1) that Resident #1 (R1) had left the facility during the night. CONTINUED LIC 809-C According to S1, on 10/11/2025, they awoke to find R1 missing and then filed a missing person report with the local police department. Later that same day, the police informed S1 that R1 was not missing but had been arrested for attempting to break into a nearby residence. S1 reported that a neighbor had contacted them and explained that R1 was caught trying to enter their home at approximately 1:00 AM, prompting the neighbor to call law enforcement. Per R1’s LIC 602 Physician’s Report, R1 is able to leave the facility unassisted; however, per the physician’s report it also says that R1 has mild cognitive impairment. S1 stated that R1 was last seen at around 10:00 PM watching television. S1 then went to bed at approximately 11:00 PM. S1 also noted that they work from 7:00 AM to 7:00 PM and require rest, and that they were the only staff members on duty that night and into the following day. Additionally, S1 reported that the facility’s door alarm is always active; however, R1 is aware of how to disable the alarm system. As a result of this post-licensing the facility is not in compliance with Title 22 Regulation. An exit interview was conducted with Administrator Kaloulasulasu and a copy of these LIC 809 reports, LIC 809-D and appeal rights along were provided to the facility.