197606175-7-10-2023-28-AS-AGOZ-CTM5DE-20230710195148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606175
Report Date: 07/10/2023
Date Signed: 07/10/2023 07:51:54 PM

Document Has Been Signed on 07/10/2023 07:51 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 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: 44	DATE:	07/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Hyun Joo (Jessica) Watanabe		TIME COMPLETED:	03:00 PM

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	Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Licensee Eugene Choi and Administrator Hyun Joo (Jessica) Watanabe. LPA Gonzalez explained the purpose of today’s visit. The facility is licensed to serve (56) elderly residents of which 24 may be non-ambulatory. There are currently only two (2) non-ambulatory residents in placement. All non-ambulatory residents are only on the 1st floor. 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. The 1st floor consist of the kitchen, dining room, activity room and medication room. 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. There was sufficient perishable and non-perishable food and the food is stored properly. The second floor consists of resident rooms and one resting room for residents. Resident rooms were randomly chosen for review 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 are 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 toilet and in the shower. Showers also have non-skid materials. The hot water was tested and was between 105.2 - 110.4 degrees, which is within the required 105 - 120 degrees. 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 in throughout the facility. (Evaluation Report continues LIC 809-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MUGUNGHWA SILVERTOWN	FACILITY NUMBER: 197606175
	VISIT DATE: 07/10/2023

NARRATIVE

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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was observed to be maintained in order and were completed accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed First Aid Kit maintained in order and complete. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters, required notifications and postings were observed throughout the facility in the different buildings located on bulletin boards and all included: Resident Personal rights, Facility sketch, Visitor policy, complaint procedures, menu and emergency disaster plan. Common areas and all indoor and outdoor passages were free of obstruction. Activity schedules observed posted throughout the facility. Administrator certificate is current and expires on 11/18/2023.

LPA reviewed Resident 1-5 (R1-5) facility files, and Staff 1-5 (S1-5) personnel files and observed that all files were in order and complete and had the required completed documents and training. Resident files contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. Staff files criminal background clearance and training, health clearance, food handling certificates, and 1st Aid/CPR training was observed.

No deficiencies during this inspection visit.

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC809 (FAS) - (06/04)

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