197610028-6-28-2024-29-AS-TBYE-D6MQFC-20240627120743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610028
Report Date: 06/27/2024
Date Signed: 06/28/2024 10:36:13 AM

Document Has Been Signed on 06/28/2024 10:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HOLLYWOOD CARE HOME		FACILITY NUMBER:	197610028
ADMINISTRATOR:	LEE, KYONG SUK		FACILITY TYPE:	740
ADDRESS:	13307 STAGG STREET		TELEPHONE:	(909) 618-7575
CITY:	N. HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	06/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Yeunje Kim		TIME COMPLETED:	12:15 PM

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Licensing Program Analysts (LPAs) Trevor Byrne Angela Barutyan and licensing program manager (LPM) KaSandra Lopez arrived at the facility unannounced to conduct a required annual visit at 09:33AM. LPAs and LPM met with representative Yeunje Kim. LPAs and LPM then spoke on the phone with administrator Kyong Suk Lee. She advised that the facility does not currently have residents. However, they will contact CCL when they plan to operate with residents again.

Beginning at 09:40AM, the LPAs and LPM, along with the representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher was fully charged and recently serviced on 04/2024. Combination smoke and carbon monoxide detectors were tested at 09:48AM and all were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN/GARAGE: The LPAs observed the garage to lack locked storage for cleaning supplies. Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies are located in a locked under-sink cabinet. Medication cabinet was observed to be locked. Water temperature was observed to be 127 degrees at 09:44AM.

COMMON AREAS: This includes the living room and dining room areas. LPAs and LPM observed common area to be clean and properly furnished at the time of the visit. The exit door in bedroom 4 (four) contained an alarm that was non-functional at the time of the visit. No other exit doors had installed alarms.

BATHROOMS: There are 2 (two) bathrooms for resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in resident bathroom 2 (two) and measured 124 (one hundred and twenty four) degrees. Resident bathroom 1 (one) was observed to have a hanging recessed light with exposed wiring.Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOLLYWOOD CARE HOME	FACILITY NUMBER: 197610028
	VISIT DATE: 06/27/2024

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BEDROOMS: There are 4 (four) total bedrooms in the facility. Resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

OUTDOOR SPACE: The backyard has patio furniture including a table and chairs for resident use but is not covered. Passageways were obstructed behind the ADU. There were no bodies of water on the premises. The entryway ramp was observed to lack appropriate safety railings.

EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's emergency disaster plan. The facility had an out of date form on display in the main entryway.

Due to no residents in care no citations were issued. Although advisory notes were issued to the licensee.

Exit interview conducted and report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

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