Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregiver staff and explained the reason for the visit. Administrators (AD) Dennis Bui and Kevin Dinh arrived shortly to assist with the visit. Facility is licensed for 6 non-ambulatory residents of which one may be bedridden in Room 3 only, with a hospice waiver for six. Currently there are four residents, two are on hospice during today's visit.

LPA Tea reviewed four resident files and two staff files. Resident files and staff files contained all required documentation. AD Bui’s Administrator certificate expires on August 15, 2026. The facility’s last fire drill was conducted on January 15, 2026.

LPA Tea along with the administrators toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The home is a two-story home that consists of three shared resident bedrooms, two full bathrooms, living room, dining room, kitchen and garage on the first floor. The second story is only for staff; no residents reside there. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109.6 to 115.3 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply

(Annual Inspection continuation on LIC809-C)