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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608842
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:56:29 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 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: 67DATE:
07/07/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Sungnam ParkTIME COMPLETED:
04:09 PM
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management – Health Check visit. LPA was met by Sungnam Park, the administrator and the purpose of today’s visit was explained.

During the visit, LPA and administrator conducted a tour of the physical plant, which includes the Reception area, TV/Entertainment Room, court yard, dining room, administrative office, lobby, kitchen, storage room, resident R1's bedroom #314, elevator, storage and activity room. LPA interviewed administrator and resident R2. LPA requested for resident R1's and R2's resident records and staff S1's staff records.



No deficiencies were observed. An exit interview was conducted and a hard copy of this report was provided to Sungnam Park.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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