LPA initiated a walk-through of the facility, accompanied by the administrator.

LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. LPA checked the appliances and observed them in working order. LPA observed a locked cabinet under the sink with knives, sharp objects, soap, and cleaning supplies, inaccessible to the residents. LPA inspected the refrigerator and pantry cabinets and observed enough supplies of fresh perishable food for (2) days and nonperishable staples for (7) days. A lockbox containing Insulin medicine was observed. No expired food was noticed.

LPA inspected the dining area and observed it clean, with all the furniture in good repair. There was a dining table and enough chairs to accommodate all the residents. LPA inspected the common room and observed sofa, chair, TV, computer stations, games, board games, puzzles, and activities items for the residents. LPA inspected the fire extinguisher mounted on the wall in the hallway and found it was fully charged with a last service tag of 03/07/2024. The administrator tested the smoke and carbon monoxide detector located in the hallway 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.

There are (4) bedrooms and (1) bathroom designated for residents' use. (3) resident bedrooms were private and (1) resident bedroom was shared occupancy. LPA inspected all (4) resident rooms and found them clean, well-lit, and equipped with the required furniture.

Continued on LIC 809-C

LPA inspected (2) storage cabinets in the hallway and observed them containing non-perishable food items, clean linens, pillows, and incontinence supplies. LPA inspected the laundry area and observed washer and dryer in working condition. LPA observed a garage containing a refrigerator with additional food supplies, storage cabinets, TV, couches, and chairs.

LPA toured the backyard area. The backyard has a set of picnic benches under a shaded area. There were no bodies of water noted and was found clear of obstructions. The passageways and ramps in the front and backyard were found clear without any tripping hazards. LPA inspected a gym deck and observed workout equipment for residents’ use. LPA asked the Administrator to send an updated facility sketch showing this gym deck.

The LPA reviewed (3) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan. LPA observed that 3 of 3 staff members had First Aid/CPR training, LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 3 of 3 staff members are associated with the facility.

LPA observed a locked centrally stored medication cabinet located inside the kitchen. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and observed it fully stocked.

The administrator counted Resident P&I money in front of the LPA and records indicated the correct amount.

LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted every (3) month, with the most recent drill completed on 11/16/2024.

The following updated forms are requested to be submitted to CCLD by 01/06/2025:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility

• LIC 999: Facility Sketch (Floor Plan)
• Certificate of Liability Insurance
• Surety Bond
• Administrator Certificate(s)

An exit interview was conducted. A copy of this report was left with the Administrator, Mark Sung, whose signature on this form confirms receipt of the report.