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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607359
Report Date: 08/11/2023
Date Signed: 08/14/2023 07:13:31 AM


Document Has Been Signed on 08/14/2023 07:13 AM - 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:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Tae Hyung Kim TIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos, conducted a required annual inspection using the Inspection Tool. LPA met with Administrator Tae Hyung Kim and the purpose of the visit was discussed.

Structure/Physical Plant: The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) resident rooms, (2) bathrooms for residents; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to clients for storage and Laundry; with washer and dryer. The residence is equipped with air conditioning. There is a inaccessible fireplace and gated pool inaccessible to residents. Accommodations: Adequate accommodations observed throughout facility. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is a cordless phone for resident use. Fire Extinguisher observed Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates observed. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working, all detectors tested and operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -110 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to residents. First aid kit observed. Postings: Required wall postings observed. Residents & Staff Files: LPA reviewed (3) of (3) Resident medication records and files , as well as three (3) Staff Files . Emergency Disaster Plan observed. Plan of Operations Observed.



Inspection tool completed and, per Title 22, deficiencies are being cited. See 809-D page. Exit Interview conducted and a copy of this report and appeal rights discussed and provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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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Document Has Been Signed on 08/14/2023 07:13 AM - It Cannot Be Edited

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: AMERICAN CARE HOME
FACILITY NUMBER: 197607359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above (2) of (3) residents had not had an appraisal completed since January 2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Facility to conduct reappraisal for resident #1 and resident #2 by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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