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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608842
Report Date: 03/24/2022
Date Signed: 03/24/2022 05:00:36 PM


Document Has Been Signed on 03/24/2022 05:00 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
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: 69DATE:
03/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Taehee Lee, RNTIME COMPLETED:
03:00 PM
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On 3/24/22 Licensing Program Analyst (LPA) Martessa Brown conducted a Case Management Visit. LPA met with Susan Sungnam Park and explained the purpose of todays visit.

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 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.

On 3/24/22 LPA Brown toured the physical plant with the administrator. LPA Brown obtained a copy of R1’s Death Certificate and the cause of death was Cardiopulomary Arrest and other health issue. This case has been closed and no follow-up is needed.

An exit interview was conducted with Taehee Lee, RN.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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