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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608842
Report Date: 04/05/2021
Date Signed: 04/14/2021 11:20:43 AM

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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SUNNY HILLS ASSISTED LIVING (MEMORY CARE)FACILITY NUMBER:
197608842
ADMINISTRATOR:SUNGNAM PARK "SUSAN"FACILITY TYPE:
740
ADDRESS:8717 WEST OLYMPIC BLVD.TELEPHONE:
(310) 659-4301
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:120CENSUS: 68DATE:
04/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Susan Park SungnamTIME COMPLETED:
04:30 PM
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On 4/5/21 Licensing Program Analyst (LPA) Martessa Brown conducted a Case Management Visit. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s Case Management was conducted telephonically with Susan Park Sungnam.

On 03/25/21 the facility faxed a Death Report regarding Resident (R1) passed away on 3/25/21.

On 4/5/21 LPA Brown met with the administrator and conducted toured the facility's physical plan; and conducted a health and safety check of residents in care. LPA interviewed the administrator and requested the following documents: R1's entire file, food menu and emergency procedure to be sent by 4/7/21 by 10:00 AM to LPA's Brown email address.

Due to additional and further review a needs further is needed to investigate.

An exit interview was conducted with administrator and provided for a return signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
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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