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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608842
Report Date: 01/30/2023
Date Signed: 03/10/2023 01:41:50 PM


Document Has Been Signed on 03/10/2023 01:41 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: 71DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Co-Administrator, Steve Yong Jin ChoTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Kim Junghee, Med- Tech. and later Steve, Co-Administrator, Steve Yong Jin Cho arrived and the purpose of today’s visit was explained. The facility is licensed to serve 120 non-ambulatory residents of which 35 may be bedridden (rooms 104 A&B, 106B,228A, 303A, 322A, 325B, 326B and 228A). Hospice waiver for a total of 10 residents.

There are currently 71 residents and which one (1) is on hospice. LPA and Co – Administrator Steve toured the physical plant. The tour consisted of the following: First Floor: Common/Reception area, TV/Entertainment Room, courtyard, dining room and kitchen, administrative office, lobby, kitchen, business office, storage room, resident bedrooms, elevator, storage area and bathrooms. Second Floor: activity room, storage rooms, resident bedrooms. Third Floor: dining room, staff lounge, storage rooms, resident bedrooms. There is also an underground parking structure and courtyards and storage area. LPA observed the residents and they appeared to be fine.

There are no bodies of water or firearm/ammunition on the premises. Residents rooms were checked. Beds and bedding were in good condition, adequate lighting provided, bathrooms and closets were inspected. LPA observed walls and floors were in good repair. Medicine room is located on the 1st floor, LPA observed medicines were stored and locked and observe residents medicine files. Bathrooms were found to be within Title 22 regulations and were clean and operational along with hand soaps, paper towel dispenser and hand sanitizers. The water temperatures measured at between 115 and120 F. A comfortable temperature is maintained in the facility.

Report continues on LIC 809-C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 01/30/2023
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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is an enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Co- Administrator, Steve provided LPA with a copy of facility Certificate of Liability Insurance.


During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Co-Administrator, Steve Yong Jin Cho.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC809 (FAS) - (06/04)
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