197608203-12-5-2023-28-AS-EZAA-CY8V6Q-20231205150955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608203
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:10:29 PM

Document Has Been Signed on 12/05/2023 03:10 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:	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	CENSUS: 128	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Dong Ho Kang - Manager		TIME COMPLETED:	03:25 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) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Dong Ho Kang, Manager of the facility, and was granted entrance. Administrator Tammie Cha arrived shortly thereafter. There are one-hundred and twenty-eight (128) residents who currently reside in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. Infection Control Plan already submitted to licensing department.

Physical Plant/Environment Safety:

· The facility is a four-story building located in Los Angeles, California. It is licensed for a capacity of one-hundred and thirty-eight (138) non-ambulatory residents, of which four (4) residents may be bedridden, and they also have a hospice waiver approved for eight (8) residents. It has seventy-one (71) residents rooms, a dining room, a kitchen, four (4) activity areas, a laundry room in the basement area of the facility, multiple shared bathrooms which measured between 105 and 120 degrees F, and two (2) patio areas in the back area of the facility.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has twelve (12) fully charged fire extinguisher located near the kitchen of the facility. There were no sharp objects that were left accessible to residents.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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 3

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: ELIM HEALTHCARE, INC.	FACILITY NUMBER: 197608203
	VISIT DATE: 12/05/2023

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

Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of one-hundred and thirty-eight (138) non-ambulatory residents, of which four (4) residents may be bedridden, and they also have a hospice waiver approved for eight (8) residents

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of twenty-seven (27) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Six (6) staff files were reviewed for criminal background clearance and training.

· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Resident Rights/Information:

· Physician orders were reviewed in six (6) resident files.

· Medication Administration Records (MARs) were reviewed along with the medications for six (6) residents.

Resident Records/Incident Reports:

· Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ELIM HEALTHCARE, INC.	FACILITY NUMBER: 197608203
	VISIT DATE: 12/05/2023

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

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· An emergency and disaster drill was last conducted on 11/7/2023.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3