Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced plan of correction visit to follow up on citations issued on 11/04/2021 and 11/08/2021. LPA was greeted and granted entry into the facility by Administrator Haeryun Cho and explained the reason for the visit. Bong Cho was present as well.

At 11:20 AM, LPA toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Inaccessible Items has been cleared. All noted items have been secured. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87608(a)(B) pertaining to Postural Supports has been cleared. Bed rails have been lowered below the bed ensuring rails are not being used. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87705(c)(5) pertaining to Medical Assessments has been cleared. Facility obtained current physician reports for residents. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87307(a)(3)(A) pertaining to Equipment and Supplies has NOT been cleared. Facility provided authorization from family for sleeping on the floor but no exception request to Licensing. Facility to submit exception request by 12/15/2021.