197608842-1-10-2024-11-AS-SLEO-CZD36B-20240110165804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608842
Report Date: 01/10/2024
Date Signed: 01/10/2024 04:58:23 PM

Document Has Been Signed on 01/10/2024 04:58 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
EL SEGUNDO ASC, 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 ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	120	CENSUS: 89	DATE:	01/10/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Steve Cho - 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	On 01/10/2024 at around 10:50 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Steve Cho. LPA explained the purpose of the visit and was accompanied by the Administrator inside and outside the facility during this inspection. This facility is licensed to serve 120 non-ambulatory residents, of which 35 may be bedridden. This facility is approved for 10 hospice residents. A total of 89 residents currently resides in this facility, of which 12 are bedridden. The facility has a balance of $1,982 in Annual Licensing Fees due on 01/29/2024. The facility is a four-story building located on a main street. The basement/first floor consists of a parking garage. The second floor consists of the medicine room, industrial kitchen, front desk, dining room, several community rooms, patio area with shaded seating, and resident rooms for assisted living. The third floor consists of resident rooms for assisted living, and community rooms. The fourth floor consists of the memory care unit, the bedridden unit, and resident bedrooms. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinets.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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 01/10/2024 04:58 PM - 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNNY HILLS ASSISTED LIVING (MEMORY CARE)	FACILITY NUMBER: 197608842
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff records did not have a health screening report and a tuberculosis test, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will email health screening report and tuberculosis test for Staff 3 to Socorro.Leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/10/2024 04:58 PM - 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNNY HILLS ASSISTED LIVING (MEMORY CARE)	FACILITY NUMBER: 197608842
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not haveing an evacuation chair, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will place an evacuation chair at each stairwell and email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 5 resident records not having an updated Medical Assessment and Appraisal & Needs Service Plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will email and updated Medical Assessment and Appraisal & Needs Service Plan for R1, R3, and R4 to Socorro.Leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNNY HILLS ASSISTED LIVING (MEMORY CARE)	FACILITY NUMBER: 197608842
	VISIT DATE: 01/10/2024

NARRATIVE

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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last fire drill was conducted on 12/12/2023. First aid kit is fully stocked with manual. Last annual fire inspection was conducted on 09/01/2023. There are several fire extinguishers around the facility, and they were last services on 09/01/2023. LPA did not observe an evacuation chair at each stairwell. There is a landline resident telephone on the front desk.

Several resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had First Aid Certificates, Criminal Record Clearances, Job Applications, Facility Trainings/Drills, and signed Employee Rights. 1 out 5 staff record did not a Health Screening report and Tuberculosis Test.

5 resident records were reviewed and, 5 out of 5 resident records had Admission Agreements, Consent Forms, Emergency Information, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights. 3 out 5 resident records did not have an updated Medical Assessment and Appraisal & Needs Service Plan.

Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. A violation regarding evacuation chair, staff records, and resident records.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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