197608203-12-17-2021-28-AS-BTAO-C9T2YW-20211217164924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608203
Report Date: 12/17/2021
Date Signed: 12/17/2021 04:49:36 PM

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:	ELIM HEALTHCARE, INC.		FACILITY NUMBER:	197608203
ADMINISTRATOR:	TAMMIE CHA		FACILITY TYPE:	740
ADDRESS:	1126 S. WESTMORELAND AVENUE		TELEPHONE:	(213) 736-7777
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90006
CAPACITY:	142; 142	CENSUS: 74	DATE:	12/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Jean Kim, Licensee Tammie Cha, Administrator		TIME COMPLETED:	05:00 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) Tao conducted an unannounced annual inspection visit. Upon arriving at the facility, LPA met with Jean Kim, Licensee and explained the purpose of the visit. About an hour later, Administrator, Tammie joined and assisted with the visit. Facility is a Residential Care Facility for the Elderly, licensed to serve elderly residents age 60 and above, and approved for 138 non ambulatory residents and 4 bedridden residents. Facility may retain eight (8) hospice residents. Memory care wing is on second floor in Room # 218-230. The facility has a capacity of 142 residents. Annual fee is paid and current.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, resident medication and food supply were reviewed.

A physical tour was conducted. This facility consisted of four (4) floors. Memory care unit was on the second floor. Medication room, kitchen, administration office, dining room, and library were located at the first floor. The front lobby and dining room areas were clean and appropriately furnished for the comfort and safety of residents. LPA observed passageways were free and clear from obstruction. Laundry room was located in the basement. There was also a laundry room located on every floor.

LPA observed residents' bedrooms are clean consisted with beds, dressers, chairs and closet space available. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. Adequate linen and personal hygiene supplies.

(-Continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELIM HEALTHCARE, INC.	FACILITY NUMBER: 197608203
	VISIT DATE: 12/17/2021

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

Bathrooms inspected were clean and operable with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 108.9 to 110.1 degrees Fahrenheit which was within Title 22 Regulation guidelines.

There were no pools and bodies of water on the premises. There were no firearms on the premises. Facility maintained a comfortable temperature for residents. Outside perimeter were free of obstruction and have shaded areas with ample seating.

The last fire drill was conducted on 11/23/21. Smoke detectors and carbon monoxide detectors were monitored by a fire alarm company, CV Fire protection. The last fire protection system test was on 7/19/21. Fire extinguishers were fully charged and last service was on 4/6/21. The emergency call for assistance/emergency system was tested and caregivers arrived to respond to the calls in 3- 5 minutes. Audio devices were tested and operable. Sufficient supply of perishable and nonperishable foods were observed.

Medication were centrally stored in a locked Medication room and inaccessible to residents. Medications were properly logged and current. Resident records were stored in a locked room and inaccessible to residents. Administrator Certificate would be expired on 3/1/22.

Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored. The first aid kits were fully stocked with a manual. Mandated documents and signages are posted in common areas.

No deficiencies were observed per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2