Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) John Tanaka .

LPA observed 2 staff and 2 residents in the facility. LPA observed a visitor (V1) in the living room. ADM stated V1 helps for grocery shopping.

LPAs checked 2 resident record files (R1 - R2) and 2 staff record files (S1 - S2).

LPA toured the facility inside out with ADM. Living room, kitchen, dinning room and two restrooms were inspected. Three shared resident bedrooms, garage, and laundry room were inspected. One staff live-in room was observed in facility. One of the three resident bedrooms was observed without screen window. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet were observed locked. Dish washing soap liquid bottle was observed placed on the kitchen counter. ADM placed the dish washing soap liquid bottle in a closet and locked it before LPA finished the annual inspection. Room temperature was at 74 degree F, and hot water temperature was at 107 degree F in facility. First aid box, flash lights and night lights were observed in the facility.

Fire extinguisher was observed on service on 05/06/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. The last time the facility conducted the emergency drill is on 5/3/2024.

Deficiencies were noted today. Exit interview was conducted with ADM. The report were provided to ADM for signature. LIC809-D and Appeal Right were attached. A copy of the report were provide to ADM.