Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Hyo Seon Kwak, Caregiver and explained the purpose of today's visit. Shortly after, Eunice Kim, Administrator and John Kim, RN arrived and assisted LPA. The facility is approved for age range 60 and over, approved for capacity of (4) ambulatory and (2) non ambulatory. Facility has approved hospice waiver for (6) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices are maintained and staff are adhering to infection control requirements. The use of Infection Control procedures are reviewed/updated. Staff ensure that residents are regularly observed for physical, mental, emotional and social functioning changes. Staff ensure that appropriate assistance is provided and such changes are documented and brought to the attention of the residents' physician.

Operational Requirements: The Infection Control Plan has been added to the Plan. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid, expires on 07/07/2026.

Physical Plant & Environment Safety: This facility is a single story home consists of kitchen, dining room, living room, (4) resident bedrooms, (1) office, (3) bathrooms, attached garage, and a shaded patio with seating. Currently, there are (6) residents living in the home. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. L P A observed a fire extinguisher near the dining area purchased on 09/08/2025. Knives, cleaning solutions, and disinfectants are lo cked and inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. LPA observed a shed in the backyard being used as a resting area/bedroom for staff. There are surveillance cameras in the common areas. *****Refer to LIC 809C for the continuation of this report.*****