LPA attempted to review resident and staff records. A newly admitted resident’s file was incomplete and did not contain all required documentation. LPA reviewed a previous resident’s file, which was complete and contained all required records. There were no staff files available for review, as LE/AD Kim is currently the only staff person at the facility. The Administrator’s Certificate is valid through November 24, 2026.

LPA along with LE/AD Kim conducted a tour of the facility, including the physical plant, food service, and first aid supplies. The facility is a single-story home consisting of three shared resident bedrooms, one staff room, two and one-half bathrooms, a living room, kitchen, dining area, and an attached two-car garage. LPA observed that smoke detectors and carbon monoxide detectors in common areas and bedrooms were present and operational. Resident bedrooms were furnished with required items, including beds, linens, and adequate storage space. Bathrooms were inspected and found to be in working condition; toilets and faucets operated properly, grab bars were secure, and showers were free of mold and mildew. The hot water temperature measured 94.6°F, which does not meet regulatory requirements.

Common areas were generally clean; however, hallways were not fully clear, as a bed frame was observed obstructing the hallway leading to the garage. The first aid kit was inspected and contained all required items, including bandages, dressings, tweezers, a thermometer, and scissors.

(Annual inspection continued on LIC809C)

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

LPA reviewed emergency preparedness. Emergency water supplies were available in the garage; however, there was no designated emergency food supply. No disaster drills had been conducted or documented.

The outside area was inspected and found to have two self-latching exit gates on both sides of the house. The backyard contained patio furniture with an umbrella for resident use. Activities provided by the facility are based on residents’ preferences and health conditions and include options such as light exercises. During the visit, LPA observed one resident resting in their bedroom.

LPA attempted to review medication storage and administration. Medications are stored in a locked cabinet in the kitchen area; however, no medications were present at the time of inspection, as the current resident had been admitted the day prior.

The following deficiencies are being cited in accordance with Title 22, Division 6, of the California Code of Regulations.

This report was reviewed with the Licensee/Administrator Tae Sun Kim. Copies of LIC 809, LIC 809-C, LIC 858, LIC 859, LIC 809-D, LIC 9102TV, and Appeal Rights were provided.