Routine inspection·August 21, 2025

On 08/21/2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Harue Seki and explained the purpose of the visit. Administrator Harue assisted with today’s visit. Administrator certificate # is 6032138740 and will expire on 04/27/2027. The current census is 6 with 3 facility staff. This facility is a single story building licensed to serve five (5) non-ambulatory residents and one (1) can be ambulatory in room #3. The facility is approved for 2 hospice waiver. 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 116.8 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mats 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 kitchen and was last serviced on 04/25/2025. LPA Lee observed the facility has a has a public telephone in the common area and the facility has the required posters posted. CONTINUED LIC 809-C Facility thermostat was observed at 76 degrees Fahrenheit. LPA Lee observed toxins located outside in a storage 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 Lee reviewed 3 out of 6 residents' Medication Administration Records (MARs), along with the medications stored in the residents' medication boxes and found them to be complete. The first aid kit was checked and contained the required components. LPA Lee requested residents and staff files for review. LPA Lee reviewed resident files, and they were completed LPA Lee reviewed staff files, and it was also 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 08/28/2025 at the 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 Harue and a copy of these LIC 809 reports were provided to the facility.