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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606175
Report Date: 06/29/2021
Date Signed: 08/02/2021 08:08:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MUGUNGHWA SILVERTOWNFACILITY NUMBER:
197606175
ADMINISTRATOR:ESTHER HONGFACILITY TYPE:
740
ADDRESS:1423 S. MANHATTAN PLACETELEPHONE:
(323) 373-1980
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:56CENSUS: 31DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica WatanabeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Administrator Jessica Watanabe and the purpose of today’s visit was explained.

There are currently (31) residents in the facility. The facility is licensed to serve (56) elderly residents of which 24 may be non-ambulatory. There is currently only one (1) non-ambulatory resident in placement.

LPA and Administrator Jessica Watanabe toured the facility's physical plant inside and outside to ensure there are no health and safety hazards. LPA toured the common areas, resident rooms which include private restrooms, kitchen, dining area, public restrooms and outside patio/ smoking area. The facility is a two story building and there are 12 resident rooms located on the first floor and 16 resident rooms located on the second floor. All common areas were properly furnished and appeared comfortable. All rooms that were inspected have private restrooms. Resident bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. All bathrooms were observed to be clean and had the required hygiene items. Bathrooms all have a supply of hand soap and paper towels. Bathrooms had grab bars for each toilet, bathtub/shower and LPA also observed non-skid mats and/ or strips in resident bathtubs/ shower. Linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents. The hot water temperature measured 117.2, which is within the required 105 - 120 degrees. All bathrooms were observed to be clean. There is sufficient lighting throughout the facility. There are no large bodies of water on the premises such as pools. The grounds are well groomed and there were no hazards observed. Cleaning supplies are inaccessible to clients. The front exterior of the facility is clear of debris with steps and ramp leading to the facility entrance. Trash containers have covered lids. There are no security bars nor weapons on the premises. There is a first floor laundry room with washer/dryer machines for resident and staff use and they are in operable condition.

SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MUGUNGHWA SILVERTOWN
FACILITY NUMBER: 197606175
VISIT DATE: 06/29/2021
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LPA observed that required documents are posted as mandated. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. Medications are properly stored, locked and inaccessible to clients. Resident Medications and files are current. Staff files are current.

LPA observed an ample supply of perishable and nonperishable food. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed hand sanitizer stations throughout the facility. LPA observed facility staff wearing masks, 2 resident bedroom located in the first floor will be converted to an isolation rooms (when needed) and required postings throughout the facility. The residents temperature's are checked and logged twice a day in the AM and PM. Facility has an adequate amount of PPE and facility has enough PPE for 30 days.

According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Jessica Watanabe and copy of report provided.

SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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