Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting a plan of correction (POC) visit for deficiencies issued during the annual inspection on November 4, 2025. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Haeryun Cho and discussed the purpose of the visit.

LPA toured the facility to inspect that the deficiencies have been corrected with AD. LPA observed that the stove burners turn on without a lighter and are operational. Thus, clearing Type B deficiency CCR 87303(a).

AD informed LPA that the staff file that needed to be updated for the POC was no longer employed at the facility. LPA observed current staff files and observed them to have a health screening and TB test. Thus, clearing Type B deficiency CCR 87412(a)(11).

LPA observed updated annual staff training completed in the current staff files as the staff file observed during the annual inspection no longer is employed at the facility. Thus, clearing Type B deficiency HSC 1569.625(b)(2).

Based on observations made during today’s visit, all Plan of Corrections have been fulfilled by the assigned POC due date of November 25, 2025. An exit interview was conducted and a copy of this report and clearance letters were left at the facility.