Routine inspection·March 10, 2026

On 03/10/2028, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required annual 1 year inspection visit. LPA met with the Administrator Lei Bi and explained the purpose of today's visit. During today's visit there are 5 residents present and 1 is in the hospital due to illness. There are 3 staff present and the administrator. This is a two level facility. Resident reside on the ground floor only. The second floor is housed only by staff at this time. There is a keypad locked door in the kitchen that leads to the second floor. This facility is licensed for 6 residents, 60 and over, whom all may be non-ambulatory. Hospice waiver on file for 2 residents. During today's visit there are 2 residents on hospice. LPA inspected the kitchen and found it clean, with breakfast preparation and cooking in progress at the time. Lunch was also being prepared for cooking. The appliances were checked and observed to be in working order. LPA inspected a locked cabinet containing knives and sharp objects below the cooking range. Resident medications are locked as well with resident files on a lower cabinet adjacent to the cooking range. The refrigerator and pantry cabinets are inspected as sufficient in supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted in the refrigerator. Dining table is in the kitchen. The large living room area is observed as clean, with all furniture in good repair. There was a sofa set and a television in the living room. LPA observed a fire extinguisher mounted on the wall adjacent to the living room are and found it fully charged, with the last service tag dated 01/21/2025. Facility has a hard wired combination smoke and carbon monoxide detector in the living room which is central to all resident rooms. Continued on LIC809-C Page 2 There are 6 bedrooms and four 4 bathrooms designated for residents' use. All 6 rresident rooms are single occupancy. All resident rooms are found to clean, well-lit, and equipped with the required furniture outlined in Title 22. Storage closets with incontinence supplies are in every resident room. LPA inspected bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring. Water temperature is tested in two resident restrooms at 113F. Linen closet is observed adjacent to the living room as sufficiently supplied. The garage contains the washer, dryer, a refrigerator, a freezer containing additional food supplies, a cabinet with detergents, disinfectants, and cleaning supplies are observed. A walk around of the outside perimeter and the backyard is conducted and is observed as safe with fencing in place, no hazardous items or materials, and emergency exit routes are free and clear of any obstructions. LPA reviewed resident and staff records and found both to be current and complete. Staff training is in place and first aid cards are present. Last fire drill conducted was on 12/19/2025 per records observed, which was a fire drill that took place. LPA inspected the first aid kit and found it fully stocked as well during today's visit. Medications and its records are observed to be current and logged accurately. - LIC500 Personnel Report - LIC308 Designation of Facility Responsibility - Certificate of Liability Insurance - Copy of Administrator Certificates No citations issued on this day. Report is reviewed with Lei Bi and a copy is provided.