Routine inspection·June 27, 2025

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Qing Guo. During the visit, LPA observed 4 residents and 3 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 4 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA observed the storage shed in the backyard being used as storage. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured to range from 112-114 degrees F in resident bathrooms. Fire extinguisher was serviced in October 14, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 10, 2025. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents. Page 1 Out of 2. LPA reviewed facility records for 2 staff and 2 residents. Based on a review of R1's Physician's report, dated April 23, 2025, R1 has a neurocognitive disorder. R1's Needs and Service plan is dated July 16, 2021. Facility ADM stated she has not updated R1's Needs and Services plan. Based on a review, R2's Physician's report is dated May 28, 2023. R2's Needs and Services Plan is dated June 3, 2023. LPA asked ADM if she has an updated Needs and Services Plan for R2, ADM stated no. LPA asked ADM if she requested a new physician's report for R2. ADM stated she did not. LPA asked if resident R2 refused to see his/her doctor, ADM stated no. ADM stated she did not ask the family of R2 to get an updated physician's report. LPA provided ADM with PIN 24-09-ASC Updated Dementia Care and Miscellaneous Regulations for Residential Care Facilities for the Elderly & PIN 25-05-ASC Updated Medical Assessment for Residential Care Facilities for the Elderly (LIC 602A) Form, including a copy of the new updated LIC602A form. Deficiencies cited during today's visit. This report was reviewed with Administrator Qing Guo and a copy of the signed report was provided. Appeal rights were provided. Page 2 Out of 2. END OF REPORT