Facility Evaluation Report

Licensing Program Analysts (LPAs) Bennette Pena and Gabriela Castro conducted an unannounced Required- 1 year visit. LPAs were met by Rosa Lee, Care Staff and John Kim, Registered Nurse (RN) and explained the purpose of the visit. Shortly after, Administrator Eunice Kim arrived and assisted LPAs with the inspection. The facility is approved to serve elderly residents, age 60 and over, (6) ambulatory of which (3) may be non ambulatory, Facility has approved hospice waiver for (2).

LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as hand soap and toilet paper.

Operational Requirements: A fire clearance is in place. Fire Drill is conducted monthly and the last drill was conducted in July 2025. Facility has working signal systems in exit points . Facility maintains liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate and expires on 07/14/2026.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (1) staff bedroom (not on sketch), (2) bathrooms, living room with covered fireplace, kitchen, dining area, laundry area in the attached garage and backyard with shaded patio area. There are currently (3) residents, 60 years and older residing in the facility, of which (1) is bedridden and no one is under hospice care. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPAs observed cameras in the common areas with no audio. Backyard was inspected and has a shaded area and sitting area. There is (1) fire extinguisher in the facility which was purchased on 09/08/2025. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit.*****REPORT CONTINUED ON LIC809-C*****