198204402-8-26-2024-28-AS-MGFS-D8HPJV-20240826112211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204402
Report Date: 08/26/2024
Date Signed: 08/26/2024 11:22:30 AM

Document Has Been Signed on 08/26/2024 11:22 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BLESSED SACRAMENT SISTERS OF CHARITY, INC.		FACILITY NUMBER:	198204402
ADMINISTRATOR:	EUNMI KONG		FACILITY TYPE:	740
ADDRESS:	248 SOUTH MARIPOSA AVENUE		TELEPHONE:	(213) 389-7760
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY:	6	CENSUS: 3	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Eunmi Kong - Administrator		TIME COMPLETED:	11:35 AM

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) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Eunmi Kong and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory elderly residents age 59 and over. Approved Hospice Waiver for 2. The facility is in a residential area and consist of a two-story home and consist of (4) resident bedrooms,(3) bathrooms (1) visitor's bathroom, kitchen, activity area, family hall with a prayer room, foyer, and office, dining room, laundry room located inside the kitchen area, front porch, and a backyard. Second floor is inaccessible to the residents. LPA Flores conducted a tour with Eunmi Kong and observed the following: Facility is in good repair indoor and outdoor. Each common area is clean with furniture in good repair. Each resident bedroom has the required furniture, bedding supplies, and sufficient lighting. Bathrooms are in good repair and water temperature was tested at 111.5 degrees F. Kitchen was observed clean with sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Sharps were observed lock in a drawer. Cleaning supplies are inaccessible to the residents. Carbon Monoxide/Smoke detectors were observed throughout the facility in working condition. No large bodies of water were observed. Ramps and passage ways are clear. Backyard has a covered/shaded seating area. LPA reviewed 3 resident files and medication and 3 staff files. Staff has been provided 20 hours of yearly training. However, training on postural support, hospice, health services and restricted conditions was not provided to staff. There are no residents on hospice or home health care at this time. Facility does not have a copy of Infection Control Plan at the time of the visit. However, they are following infection control prevention. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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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Document Has Been Signed on 08/26/2024 11:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BLESSED SACRAMENT SISTERS OF CHARITY, INC.	FACILITY NUMBER: 198204402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in facility last emergency drill was on 5/1/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2024
	Plan of Correction
1 2 3 4	Administrator will conduct an emergency drill with staff and residents and will maintain a log and provide a copy to the department by POC due date 9/2/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BLESSED SACRAMENT SISTERS OF CHARITY, INC.	FACILITY NUMBER: 198204402
	VISIT DATE: 08/26/2024

NARRATIVE

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Emergency Disaster plan was available for review. However, pages 4 to 9 were not filled out. Last emergency drill was conducted on 5/1/23 per administrator. Administrator certificate was observed for Eunmi Kong #7035628740 exp. date: 11/10/25.

Deficiency was noted on LIC 809D and technical violations and assistance were provided.

Exit interview was conducted with Eunmi Kong and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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