Routine inspection·July 7, 2025

On July 07, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Alan Tuan, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had (12) residents in care and (3) staff members present at the time. At 8:55 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. The indoor temperature reading of 75°F on a thermostat was observed in the hallway at the time of the visit. LPA inspected the kitchen and observed breakfast service was in progress at the time. The appliances were checked and observed to be in working order. The LPA observed a locked lock box on the kitchen countertop containing knives and sharp objects. LPA inspected a locked cabinet under the sink containing detergents, disinfectants, and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for two (2) days and nonperishable staples for seven (7) days were observed. No expired food or stored medications were noted. LPA inspected the dining area adjacent to the kitchen. One (1) resident was observed to be sitting in the dining area eating breakfast. LPA inspected the living room and observed a sofa, chairs, tables, a piano, and a television in the living room. Two (2) residents were observed sitting in the living room watching TV. Board games, puzzles, arts, coloring, bingo, and other recreational activity items for residents’ activities were also observed in the living room. LPA inspected the fire extinguisher mounted on the wall in the hallway and found it fully charged, with the last service tag dated 07/10/2024. The Administrator tested the smoke and carbon monoxide detector located in the office room in the LPA's presence, and it was found to be functional. Continued on LIC809-C There were fifteen (15) bedrooms designated for residents' use. All (15) resident rooms were single occupancy. LPA inspected random six (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA inspected half bathrooms in these random rooms and found them in working condition. The bathrooms contained soap, grab bars, towels, and a trash can. The hot water temperature at the sink faucet measured between 118.2°F to 119.5°F in these bathrooms. LPA observed men and women bathrooms in the hallway for shower with a shower chair, non-slip mats, and grab bars. LPA observed a laundry area in the hallway with a washer and a dryer. The laundry detergents, cleaning solutions, and disinfectants, were observed locked in a closet next to the backside door. LPA inspected a dresser in the hallway and observed it containing clean linen supplies. LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard had a set of a patio table, chairs, and a gazebo for resident use. No accessible bodies of water were found. LPA inspected one (1) storage shed and observed refrigerators, freezers, and pantry food items stored in the shed. At 10:25 AM, LPA reviewed five (5) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement and current Physician's Report. LPA observed that 3 of 5 residents did not have Pre-Admission Appraisal, 5 of 5 residents didn’t have Functional Capabilities Assessment, and 4 of 5 residents didn’t have current Appraisal Needs and Services Plan. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements, LIC 503 Health Screening, current first aid certificates, and confirmed that 5 of 5 staff members were associated with the facility. LPA observed a locked centrally stored medication cabinet located inside in the hallway near the backside door. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. At 11:35 AM, LPA asked the Administrator for an Emergency Disaster Drill log. The Administrator didn’t have Emergency Disaster Drills logs for LPA to review, and LPA was not able to verify if the drills are conducted quarterly at the facility. Continued on LIC809-C LPA inspected the first aid kit and found it fully stocked. The following updated forms are requested to be submitted to CCLD by 07/14/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Alan Tuan, whose signature on this form confirms receipt of these documents.