Routine inspection·January 30, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with House Manager Mary Grace Yongco (HM). LPA observed 1 staff in the facility. All 5 residents went to day program. HM stated the facility is a level 4c RCFE facility. License, Personal Rights posters, and Administrator Certificate were observed in the facility. LPA observed the facility has emergency lighting system. LPA reviewed 3 resident files and 3 staff files. LPA toured the facility with HM inside and out. LPA inspected living room, kitchen, dining area, 4 residents rooms, 2 bath rooms, and 1 meeting room. Two days perishable foods and seven nonperishable foods were observed sufficient. The temperature of the refrigerator was observed at 37 degree F, and the temperature of the freezer was observed at 0 degree F. Room temperature was observed at 70 degree F. Hot water was observed at 112 degree F. Medication cabinet, and knife closet, were observed locked. Dish washing solution bottle was observed on the top of sink in the kitchen, HM locked the dish washing solution bottle in the closet in kitchen immediately. Fire extinguisher was serviced on 1/16/2025. The facility was equipped with fire alarm system and carbon monoxide detectors. Fire alarm and carbon monoxide detectors were tested, and were functional. First Aid box, flash lights, and night lights were observed in the facility. The facility's last time conducted the fire drill was on 1/13/2025. Front yard and back yard were inspected. There is a storage room in the backyard. No obstruction was observed to block the walkways. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of this report was provided to HM.