Routine inspection·July 2, 2025

Licensing Program Analysts (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mina Abbasvand . LPA observed 5 residents and 2 staff in the facility. LPA reviewed 3 residents files and 3 staff files. Resident R1's medications and centrally stored medication forms were observed mismatched. LPA toured the facility inside and out and ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. Living room, kitchen, dinning room, three restrooms, six single resident bedrooms, and laundry area were inspected at the first floor. 4 beds in 4 bedrooms were observed with bed rails, ADM provided the documents for residents to us bed rails. 4 staff live-in rooms and one bathroom were observed at the second floor. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet and knives closet were observed locked. Cleaning products were observed locked. Dish washing soap closet under the sink was observed locked. Room temperature was at 74 degree F, and hot water temperature was at 110 degree F. The temperature of the refrigerator was at 40 degree F and the temperature of the freezer was observed at 0 degree F. Door alarms were observed working. ADM tested the call button system and call light system, and were working. First aid box, night lights ,and flash lights were observed at the facility. The last time the facility conducted the emergency drill was on 4/14/2025. Continue on LIC809-C. Page 1 of 2. Fire extinguisher was serviced on 2/18/2025. The facility is equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detector was tested by staff, and were working. Front yard and backyard were inspected. There was no obstruction to block the walkways. The garage was observed a storage room inside. Deficiency was noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. Page 2 of 2.