197606175-11-1-2021-28-AS-CYEE-C9C85M-20211202211258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606175
Report Date: 11/01/2021
Date Signed: 11/01/2021 12:17:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2021 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211029134624

FACILITY NAME:	MUGUNGHWA SILVERTOWN		FACILITY NUMBER:	197606175
ADMINISTRATOR:	ESTHER HONG		FACILITY TYPE:	740
ADDRESS:	1423 S. MANHATTAN PLACE		TELEPHONE:	(323) 373-1980
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	56	CENSUS: 36	DATE:	11/01/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jessica Watanabe		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following COVID-19 guidelines.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Licensee Eugene Choi and Administrator Jessica Watanabe and explained the reason for the visit.

The investigation consisted of: On 11/01/21, LPA Gonzalez conducted interviews with the following facility staff: Licensee Eugene Choi, and Administrator Jessica Watanabe. LPA collected copies of Staff and Resident Rosters and Visitor Sign-In Sheet dated 9/4/21 - 11/1/21. LPA also reviewed facility Mitigation Plan.

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20211029134624

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: Regarding allegation, Facility is not following COVID-19 guidelines, it is alleged that facility staff did not conduct COVID-19 screening on two separate occasions. Facility administrator was allegedly educated on the importance of screening visitors upon entry to the facility on 8/2/21 and subsequently did not screen the same visitor on a follow up visit conducted on 10/6/21. Interview conducted with Administrator Jessica Watanabe revealed that facility staff are following COVID-19 guidelines and do screen visitors. She stated that visitors have to sign in and their temperatures are taken and logged. She stated that the facility does not get too many visitors and that many visitors conduct their visits outside in the visiting area located in the outside patio. Administrator stated that she did not screen or take the temperature of representatives from agencies such as CCLD (Community Care Licensing Division or LTCO (Long Term Care Ombudsman) as she is aware that those agencies conduct testing and their own screening process prior to the agency representatives conducting on site visits to facilities. Interview conducted with Licensee Eugene Choi revealed that facility is following COVID-19 guidelines at all times and stated that facility will now also ensure that visitors from any government or local state agency are also screened as well as their temperatures taken.

On 11/1/21, LPA Gonzalez was not screened and temperature was not taken by facility staff upon entry into the facility. LPA reviewed facility mitigation plan and observed that mitigation plan states that anyone entering the facility signs in and has their temperature taken as well as symptoms checked and anyone entering the facility is required to wear a mask inside. LPA observed all staff wearing masks. LPA also reviewed visitor sign-in sheet and observed that visitors have been screened and have had their temperature checked and logged.

Based on interview conducted with facility staff and LPA review documents and observations, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22.

Exit interview was conducted with Administrator Jessica Watanabe. A copy of the report and appeal rights were provided to Administrator.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211029134624

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/02/2021 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter: Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California	1 2 3 4 5 6 7	Licensee and Administrator agreed to ensure that facility is following California Dept of Public Health and CCLD requirements. Licensee/ Administrator will submit proof of staff re-training in COVID-19 infection control requirements, and will maintain a safe and healthful environment for residents and staff.
	8 9 10 11 12 13 14	This requirement was not met by evidence of: On 11/1/21, LPA was not screened and temperature was not taken upon entry into the facility per COVID-19 Infection control recommendation. In addition, Administrator stated that they did not screen representatives from agencies such as CCLD or LTCO due to those agencies doing their own screening. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3