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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606175
Report Date: 07/01/2024
Date Signed: 07/01/2024 04:23:42 PM


Document Has Been Signed on 07/01/2024 04:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 42DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Hyun Joo (Jessica) WatanabeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an annual inspection visit. LPA was allowed entry by Administrator Jessica Watanabe. LPA discussed the purpose of today’s visit.
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The facility is licensed to serve (56) elderly residents of which 24 may be non-ambulatory. There are currently three (3) non-ambulatory residents in placement. All non-ambulatory residents are only on the 1st floor.

The facility is a two story building which consists of the following: 12 resident rooms located on the first floor and 16 resident rooms located on the second floor. The 1st floor consist of the kitchen, dining room, activity room and medication room. The second floor consists of resident rooms and one resting room for residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility does has an Infection Control Plan in place.

Operational Requirements: Facility is adhering to the operational requirements.

Physical Plant & Environment Safety: LPA toured facility grounds. The furniture in the dining room was adequate and the kitchen was clean. The appliances were working properly. The refrigerators and freezer are set at appropriate temperatures. LPA toured resident rooms which were randomly chosen for inspection on both floors. There are smoke detectors and fire extinguishers located throughout the building. The hallways and stairways are clear and free of any obstructions. Resident rooms were observed to be clean, properly furnished and have the required linen which were in good condition. There was adequate lighting throughout the facility. All resident rooms had appropriate storage for resident's personal belongings. The bathrooms have the required grab bars near the

**Continued on LIC809C**
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MUGUNGHWA SILVERTOWN
FACILITY NUMBER: 197606175
VISIT DATE: 07/01/2024
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toilet and in the shower. Showers also have non-skid materials. The hot water was tested and was between in random resident rooms and was between 105.2 - 110.4 degrees, which is within Title 22 regulations. Restrooms were observed to be clean, and operational. There is 1 elevator and the elevator was operating at the time of the visit. There is no pool or large bodies of water on the premises. A comfortable temperature was maintained throughout the facility.

Staffing: Facility is adhering to staffing requirements.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and Staff 1-3 (S1-3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Resident Rights-Information: Resident rights are posted and included in Resident files.

Planned Activities: Activity schedule is posted.



Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident 1-4 (R1-4). Resident files are maintained at the facility. Resident files have the required documents.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.



Residents with Special Health Needs:
Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. Per Administrator, there are (0) residents utilizing oxygen equipment.

Health Related Services/Incidental Medical Services: The medications are stored/ locked inside the medication room and are inaccessible to residents.

Exit interview conducted, and a copy of this report was provided to Administrator Jessica Watanabe.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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