Orange Senior Home

Type of visit: POC

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Plan of Correction (POC) inspection visit to verify correction of deficiencies cited during the facility's Annual Required Inspection conducted on 05/01/2026. LPA was greeted by and granted entry into the facility by Licensee/Administrator (LE/AD) Tae Sun Kim. LPA explained the purpose of the visit. During today's inspection, LPA toured the facility with the administrator to verify that the cited deficiencies had been corrected. LPA reviewed and verified required documentation, including the submission of a death report for a resident who was receiving hospice services and passed away. LPA confirmed that the facility maintains current liability insurance coverage. Water temperature was tested and measured at 115.0°F, which is within department standards. LPA verified that all pathways throughout the facility were free of obstructions and that resident and staff rosters had been completed and updated. Resident and staff files were reviewed and found to be complete and organized. LPA also verified that required annual staff training had been completed. LPA confirmed that the facility maintained an adequate supply of emergency food and water and verified that the most recent quarterly emergency disaster drill was conducted on 04/21/2026. Based on observations and records reviewed during today's inspection, LPA determined that the facility has corrected all cited deficiencies and fulfilled the Plan of Correction requirements by the assigned due date of 06/01/2026. Therefore, the following Type B deficiencies are cleared: CCR Sections 87211(a)(1), 87303(e)(2), 87307(d)(6), 87412(f), 87413(a)(1), and 87506(a); and Health and Safety Code Sections 1569.605, 1569.625(b)(2), 1569.695(a)(2), 1569.695(c), and 1569.695(e)(1). An exit interview was conducted with Administrator Tae Sun Kim, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Annual Required inspection of the facility. LPA was greeted by Licensee/Administrator (LE/AD) Tae Sun Kim, who granted entry. The purpose of the visit was explained. The facility is licensed to serve six ambulatory residents and has a hospice waiver for six residents. At the time of the visit, there was one resident in care. 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) The kitchen was inspected, and both perishable and non-perishable food supplies were adequately stocked at the time of the visit. LPA observed that sharp objects were secured in a locked kitchen cabinet. Toxic substances were stored in the laundry area and were inaccessible to residents. Fire extinguishers throughout the facility were fully charged, and all kitchen appliances were operational. 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.the state’s words, verbatim · CDSS document, May 1, 2026

The state marks this report as 10 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Michael Tea made an announced inspection visit to follow up on corrections identified during a Pre-Licensing visit on 04/03/2025. LPA Tea was greeted and granted entry by Licensee/Administrator Tae Sun Kim. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCLD on 01/25/2025 for a total capacity of six ambulatory only. Fire clearance was approved by a fire inspector from the Orange County Fire Authority on February 10, 2025. At around 8:50 AM LPA toured the facility and observed the following: · An umbrella for shade in the backyard · Administrator Certificate with an expiration date of 11/24/2026 posted in the front entry way · “See Something Say Something” (PUB 475) Poster posted in the front entry way · Ombudsman Poster posted in front entry way · First Aid Kit with all the required elements: thermometer, tweezers, bandages, dressing, scissors · First Aid Booklet · Backyard was clear of hazards and obstructions · Windows and door had alarms/alerts · Telephone available for residents to use Noted items from the prior visit on 04/03/2025 have been addressed. The facility is ready to be licensed. LPA conducted the Component Three Orientation with Licensee/Administrator Tae Sun Kim. Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Michael Tea made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Tea met with designated Administrator (AD) Tae Sun Kim. An application to operate a Residential Care Facility for Elderly (RCFE) was received by our agency on January 14, 2025 for a total capacity of six ambulatory only. Fire clearance was approved by a fire inspector from the Orange County Fire Authority on February 10, 2025. The facility is a one-story home with three resident bedrooms that are shared rooms, one staff room, two and half bathrooms, a living room, a kitchen, a dining area, and an attached two car garage. There are two backyard exit gates on each side of the house that are self-latching and unlocked. There is a seating area but no umbrella for residents in the backyard. LPA observed big glass tabletops that were in the backyard that needs to be disposed of for the safety of residents. LPA did not observe any administrator certificates on the wall. The See Something, Say Something poster (PUB 475) was small and did not meet the department standards. There was no Ombudsman poster posted as well. LPA did observe Personal Rights, Facility sketch and Emergency Disaster Plan in the facility mounted on the wall of the facility entryway. Fire extinguishers are located at the front entryway by the living room and garage entryway fully charged. Fire alarms and carbon monoxide detectors worked properly and are operational. Resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. All toxic chemicals, cleaning solutions, and disinfectants are inaccessible to residents and will be stored and locked in Pre-licensing Inspection continued on LIC809-C the cabinets in the laundry area. Medications will be stored in a locked cabinet in the kitchen. The first aid kit is also stored in the locked cabinet in the kitchen. The first aid kit is incomplete, the kit is missing a thermometer and a pair of tweezers. Staff and resident records will also be stored and locked in the kitchen cabinet. LPA observed activities like calligraphy and wood craving provided by the administrator in the the living room. There is no phone for the residents. There is a laptop for residents to use in the staff office area. A supply of perishable and non-perishable food was observed and will be maintained on hand. Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational. Sharps are stored in box container secured in a lock cabinet in the kitchen. Hot water temperatures in the bathrooms measured around 107.2 Fahrenheit degrees. Emergency food and water and additional supplies were observed to be well stocked in the staff area and garage. Licensee will need to address the following issues and need to be corrected to be licensed: · Umbrella for shade in the patio area · Administrator certificate · Pub 475 “See Something Say Something” Poster needs to be 20x26 · Ombudsman Poster · First Aid kit is missing: thermometer and pair of tweezers · First Aid booklet · Backyard needs to be clear of hazards such as glass tabletops · Window and door alarms or alerts. · Telephone for residents to use The facility is not ready to be licensed. Licensee will contact the LPA to schedule a second Pre-licensing visit when corrections are completed. An exit interview was conducted, and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Apr 3, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITL Capacity: 6 Census : 0 Method: Telephone call with CAB COMP II Participants: TAE SUN KIM(Administrator/Licensee) & JOSHUA DEGMETICH (Analyst). Administrator/Licensee participated in COMP II via telephone call with CAB analyst. Identification of the Administrator/Licensee was verified by confirming driver’s license number. During COMP II, Administrator/Licensee confirmed the understanding of Title 22. Component II was successfully completed. Administrator/Licensee was advised to email signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Administrator/Licensee's understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 3, 2025