An application was submitted to CCLD on 12/16/2025 for a Change of Ownership for a Residential Care Facility for the Elderly for ages 60 years and older. The fire clearance has been approved for a capacity of 120 residents, of which 110 may be non-ambulatory and 10 may be bedridden.

Physical Plant:

Facility is a two-story building consisting of 88 resident rooms. The 1st floor consists of a lobby, dining room, kitchen, administrative offices, restrooms, storage room, laundry room, resident rooms, and the Memory Care unit. The 2^nd floor consists of resident rooms, staff offices, medication room, activity room, and a fitness room. The Memory Care unit has 18 resident rooms, activity room, and has delayed egress exits. There are shaded areas with outdoor furniture in both Memory Care (MC) and Assisted Living (AL) sides. There are no swimming pool or large bodies of water on the premises. The facility has a small pond surrounded by rocks located in the Assisted Living courtyard. Inter-connected smoke and carbon monoxide detectors are located throughout the facility and linked to the local fire department. The fire extinguishers are fully charged and last inspected on 1/5/26. Nightlights are observed in the hallways. Facility has sufficient space to accommodate indoor and outdoor activities. LPA selected a total of 12 resident rooms (MC: rooms #129, #133, #138, 149; AL: rooms #105, #116, #120, #121, #203, #218, #226, #235). The rooms are equipped with appropriate furnishings and the hot water temperature was measured within the required range of 105-120 degrees Fahrenheit.

• 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.

Operational Requirements: The facility has an approved fire clearance for 110 non-ambulatory and 10 bedridden residents. All the bedrooms on the first floor are approved for bedridden. The memory care unit is approved for the delayed egress. Facility maintains the required liability insurance which expires on 11/12/26.

Staff and Residents files: Staff and Residents files are stored and maintained at the facility. LPA selected 5 staff and 5 resident files to ensure all required forms are in the files. The administrator’s (Donghyun Moon) certificate expires on 3/3/27.

Planned Activities: The facility has sufficient space to accommodate both indoor and outdoor activities. An activity calendar is posted in the lobby and the elevator.

Food Service: Sufficient food supply of 2-day perishable and a week of non-perishable are stored in the kitchen and pantry areas. The freezer was maintained at 0 degrees F and the refrigerator was at 40 degrees F. Food in refrigerators were properly covered to avoid contamination.

Incidental Medical and Dental: Resident medications are centrally stored and locked in the medication room. The facility uses the Medication Administration Record (MAR) log to document medications given.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers. Facility has an outside contractor to conduct emergency drills at least quarterly for each shift.

Residents with Special Health Needs: The facility can accept or retain up to 10 bedridden residents.

Component III: Component III was conducted during this visit.

Pre-Licensing is complete and this facility has no deficiencies. An exit interview was held and a copy of this report was given to D. Moon.