At 1:05 PM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. The indoor temperature reading of 74°F on a thermostat was observed in the hallway at the time of the visit.

LPA inspected the kitchen and observed lunch preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet under the sink containing detergents, disinfectants, cleaning supplies, knives and sharp objects. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. Two (2) residents were observed to sitting in the dining area waiting for lunch to be served.

LPA inspected the living room and observed a sofa set, chairs, a coffee table, a game table, a covered fireplace, and a television in the living room. One (1) resident was observed sitting in the living room with their family member and playing a game. Board games, puzzles, arts, coloring, audio and video disks, and other recreational activity items for residents’ activities were also observed in the living room. The door screen in the living room sliding door was observed to be broken.

Continued on LIC809-C

• 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 inspected the fire extinguisher mounted on the wall in the hallway and found it fully charged, with the last service tag dated 05/02/2025. The Administrator tested the smoke and carbon monoxide detector located in the living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit.

LPA observed a linen closet with bedsheets, blankets, and towels in the hallway. LPA observed a locked closet in the hallway containing cleaning solutions, disinfectants, and incontinence supplies.

LPA inspected the garage and observed the garage containing racks with shelves containing extra dry food items, incontinence supplies, and paper products.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard had a set of a patio table, chairs, and umbrella for resident use. No accessible bodies of water were found. LPA inspected two (2) storage shed and observed tools, wheelchairs, walkers, and furniture items in the shed.

LPA reviewed five (5) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 1 of 4 staff members didn’t have LIC 503 Health Screening. LPA confirmed that 4 of 4 staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet located inside in the dining area next to the kitchen. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete.

Continued on LIC809-C

LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 04/06/2025.

The following updated forms are requested to be submitted to CCLD by 06/10/2025:

· LIC 500: Personnel Report

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Guili Xu, whose signature on this form confirms receipt of these documents.