Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Sang Heng allowed the entry of the facility. The purpose for the visit was explained. The facility is licensed for AGE RANGE 60 AND OVER. 6 NON-AMBULATORY, OF WHICH 1 IS BEDRIDDEN. HOSPICE WAIVER FOR 3 . Facility has fire clearance for 6 non-ambulatory residents, one of which is bedridden. Currently there's no resident reside in the facility.

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

Infection Control: The facility does not have a infection control plan in file and administrator does not have a health screening report with chest x ray

Operational Requirement: The facility does not have any proof of liability insurance for the facility.

Physical Plant and Environmental Safety: The facility includes family room, dining area, kitchen, living room, three residents rooms and two bathrooms and storage room. The bathrooms are clean, sanitary and in a good working condition. The bathrooms also have grab bars and non-skid mat. LPA checked the hot water in the bathroom and its tested at 67 degrees F. and its below the range of Title 22 regulation. LPA also observed there was all purpose cleaner which are stored on top of the toilet which are not locked.

Staffing: Currently no staff is working at the facility.

Personnel Records- Training: The administrator (Sang Heng) certificate is expired and currently no staff is working at the facility.

Resident Records/Incident Reports: Currently facility has no residents reside

Residents Right Information: LPA did not observe any poster for complaint's information or resident right in the facility

Planned Activities : Currently there's no residents reside in the facility

Food Service: Currently there's no resident reside in the facility.