Inspector’s narrative
What the inspector wrote
On April 30, 2025, at 08:45 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Guili Xu, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had five (5) residents in care and two (2) staff members present at the time.
At 9:17 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. The indoor temperature reading of 72°F on a thermostat was observed in the hallway at the time of the visit.
LPA inspected the kitchen and observed breakfast preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet under the sink containing detergents, disinfectants, cleaning supplies, knives and sharp objects. 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 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 fire extinguisher mounted on the wall in the dining area and found it fully charged, with the last service tag dated 05/01/2024. LPA advised the Administrator to have the fire extinguisher serviced as soon as possible for the year 2025.
At 09:28 AM, LPA inspected the garage and observed the garage cluttered with incontinence supplies, furniture, food supplies, Christmas decorations, suitcases, several wooden doors, cabinets, wheelchairs, and mattresses.
Continued on LIC809-C
LPA inspected the laundry room next to the kitchen and observed a washer, a dryer there.
LPA inspected the living room and observed a sofa set, chairs, recliner, coffee table, covered fireplace, small refrigerator, music system, and a television. One (1) resident was observed sitting on the recliner and watching TV. Board games, chess, puzzles, arts, coloring, bingo, and other recreational activity items for residents’ activities were also observed in the living room.
The Administrator tested the smoke and carbon monoxide detector located in the living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide 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. The backyard had a set of a patio table, chairs, and umbrella for resident use. No accessible bodies of water were found. LPA inspected (1) storage shed and observed wheelchairs, walkers, and furniture items in the shed.
There were six (6) bedrooms and four (4) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. Storage closets with incontinence supplies were observed in the rooms. LPA inspected four (4) full bathrooms and found them in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower bench, and non-slip mats/flooring. At 9:46 AM, the hot water temperature at the sink faucet measured 127.8°F in bathroom #1, 126.2°F in bathroom #2, and 127.8°F in bathroom #4.
At 09:43 AM, the LPA inspected the storage space in the hallway closet and observed it containing linens for residents’ use and found that sliding door was dangling and the door track was broken on the bottom.
LPA reviewed five (5) staff personnel records and five (5) resident records. At, 10:56 AM, The LPA observed that 4 of 5 residents did not have Safeguards for property/valuables inventory filed, dated, and signed. 1 of 5 residents had last annual Physician assessment done on 2/25/2021 and 2 of 5 residents’ assessment was done in the year 2023. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.
Continued on LIC809-C
At 11:38 AM, the LPA observed a locked centrally stored medication cabinet located inside in the dining area next to the kitchen. Medications were organized in separate boxes for each resident. 5 of 5 resident’s medication prescription names, prescription numbers, and date filled were not entered correctly in the Centrally Stored Medication Records (CSMR). 5 of 5 resident’s prescription medication labels were altered with the handwritten notes on it.
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 3/25/2025.
The following updated forms are requested to be submitted to CCLD by 05/07/2025:
LIC 500: Personnel Report
LIC 308: Designation of Facility Responsibility
Certificate of Liability Insurance
Administrator Certificate(s)
The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.
An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Penny Xu, whose signature on this form confirms receipt of these documents.
