Routine inspection·September 11, 2025

On 09/11/2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Benilda Lungan and explained the purpose of the visit. The administrator, Lungan assisted with today’s visit. Administrator certificate # is 7036256740 and will expire on 05/04/2027. The current census is 4 with 3 facility staff. This facility is a single story building licensed to serve five (5) non-ambulatory residents or 4 non-ambulatory and 2 ambulatory residents. The northeast bedroom is approved for two ambulatory or 1 non-ambulatory resident. LPA Lee 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 105.1 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 dining area and was last serviced on 02/10/2025. CONTINUED LIC 809-C The last fire drill was conducted on 08/21/2025. 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 76 degrees Fahrenheit. LPA Lee observed toxins located in the garage cabinet and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 4 out of 4 resident medications and medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 4 out of 4 resident files and they were complete. LPA Lee reviewed 2 staff files, and it was 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 with the facility. The following documents will be email to LPA by 09/11/2025 end of day 5:00 PM: (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 administrator Lungan , and a copy of these LIC 809 reports were provided to the facility.