Post-licensing visit·August 4, 2025

On August 04, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Post Licensing inspection. The LPA met with the Licensee, Ying Wang, and disclosed the purpose of the inspection. The Licensee informed the LPA that the facility had four (4) residents in care and one (1) additional staff member present at the time. LPA initiated a walk-through of the facility, accompanied by the Licensee. The indoor temperature reading of 68°F on a thermostat was observed in the hallway at the time of the visit. LPA inspected the kitchen and observed lunch preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a magnetic locked cabinet containing knives and sharp objects. LPA inspected another magnetic locked cabinet under the sink with detergents, disinfectants, and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA observed the refrigerator temperature at 37°F and freezer temperature at 0°F. LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. LPA inspected the living room and observed a sofa set, chairs, a fireplace, and a television in the living room. One (1) resident was observed sitting in the living room watching TV. LPA observed three (3) hallway closets, one linen closet with bedsheets, blankets, and towels, second closet containing incontinent supplies, and the third closet with toiletries. Continued on LIC809-C There were six (6) bedrooms, three (3) full bathrooms, and one (1) half bathroom designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, equipped with the required furniture. Four (4) rooms had a sliding door exit to the outside deck/backyard access. The bathrooms contained soap, grab bars, towels, a trash can, a shower chair, and non-slip mats/flooring. The hot water temperature at the sink faucet measured between 115.8°F to 117.5°F in all bathrooms. The LPA inspected the laundry area and observed a washer and a dryer. LPA observed a locked cabinet in the laundry area containing detergents, disinfectants, and cleaning supplies. LPA inspected a locked staff break room in the garage and observed sofa, table, and chairs preset in the break room. LPA inspected the fire extinguisher mounted on the wall in the hallway and found it fully charged, with the last service tag dated 10/13/2024. The Licensee tested the carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. Additional smoke detectors were observed in all bedrooms and common areas of the facility during the visit. LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No accessible bodies of water were found. The backyard had a table, chairs, and shaded areas for resident use. LPA observed a magnetic locked centrally stored medication cabinet located inside in the dining area. Medications were organized separately for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. Medication count was found to be accurate. LPA inspected the first aid kit and found it fully stocked. LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 06/23/2025. LPA reviewed three (3) staff personnel records and four (4) resident records. The LPA observed that 4 of 4 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Consent forms, Safeguard personal property and valuables, and Personal rights forms. LPA observed that 3 of 3 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening. Continued on LIC809-C The following updated forms are requested to be submitted to CCLD by 08/11/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility No deficiencies were cited during today's visit. An exit interview was conducted with the Licensee. A copy of this report was provided to the Licensee, Ying Wang, whose signature on this form confirms receipt of the report.