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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607359
Report Date: 08/15/2022
Date Signed: 08/15/2022 03:52:44 PM


Document Has Been Signed on 08/15/2022 03:52 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:AMERICAN CARE HOMEFACILITY NUMBER:
197607359
ADMINISTRATOR:TAEHYUNG KIMFACILITY TYPE:
740
ADDRESS:12611 CULLMAN AVE.TELEPHONE:
(562) 943-9048
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 3DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH: Administrator Taehyung KimTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Taehyung Kim. The purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed three (3) resident records, three (3) staff files, and three (3) resident medications. Currently the facility has (3) residents which (2) are non-ambulatory. Facility is a one story family home with four (4) resident bedrooms, two (2) bathrooms, living room, kitchen, central air and heating, dining area, laundry room, a shaded area located in the backyard. an attached garage inaccessible to residents. Front and back yard is in good condition at time of visit. Facility has a fireplace blocked from resident use. There is a pool in the backyard fenced in and locked. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to residents. Bedrooms #1-#4 required furnishing. Bathroom have a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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