Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted a Case Management Visit-Deficiencies stemming from initial complaint investigation conducted on 7/18/25, complaint control # 28-AS-20250717142205. LPA Herrera met with Licensee Hyo Kim and explained the reason for visit.

During complaint investigation dated 7/18/25 LPA observed the following

- Medication for Resident #1 is missing from facility, all original containers for routine medication were not at facility and Licensee explained that this was because family have taken control of medication and store it with them at their home. LPA observed the LIC622 Centrally Stored Medication form stating that facility is responsible for storing medication. Type A citation will be issued.

- Medication for Resident #1 is outside of the original containers and prepacked for a total of 8 consecutive days in a separate medication container packaging dated Sunday through Mondays 8am,9am,2pm and bed. Type A citation will be issued.

- Disinfectants and cleaning solutions stored under kitchen sink were unlocked and accessible to residents. The door that separates kitchen from living room was observed to also be unlocked and open during visit from 11am-1:30pm, with staff entering and exiting kitchen, leaving area accessible to residents. Type A citation will be issued.

Details for above citations can be found on the LIC809-D page of report.

Exit interview held, and a copy of this report and appeal rights were emailed to Licensee and Administraor.