197610028-5-8-2023-29-AS-SURA-CRMLHJ-20230508084623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610028
Report Date: 05/05/2023
Date Signed: 05/08/2023 08:47:03 AM

Document Has Been Signed on 05/08/2023 08:47 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
CCLD Regional Office, 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:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Yenunje Kim		TIME COMPLETED:	02:30 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

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual visit. The LPA spoke with administrator on the phone and explained the reason for the visit. The administrator stated that they currently do not have residents, they have advertised, but it has been unsuccessful. The administrator was not present for the tour, the facility representative Yenunje Kim provided the tour.

The LPA and the facility representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The sink hot water temperature measured at 120 degrees Fahrenheit.

BEDROOMS: The residents’ bedrooms were furnished appropriately with clean linens, appropriate

furnishings and sufficient lighting.

RESTROOMS: Restrooms are clean, sanitary and in operating condition. The common bathrooms were observed with appropriate signs and stocked with paper towels. The restroom hot water temperature measured at 120 degrees Fahrenheit.

Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: HOLLYWOOD CARE HOME	FACILITY NUMBER: 197610028
	VISIT DATE: 05/05/2023

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
26
27
28
29
30
31
32

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Smoke detector(s) and carbon monoxide detector were tested, and operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 04/01/2023. The LPA observed required postings throughout the common space. The backyard has a patio area with patio furniture and umbrella for residents and family members to meet.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA discussed the new PIN changes regarding infection control.

No deficiencies cited at this time. Exit interview conducted. Signatures obtained. The report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2