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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204402
Report Date: 07/21/2025
Date Signed: 07/21/2025 11:51:41 AM

Document Has Been Signed on 07/21/2025 11:51 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/
DIRECTOR:		EUNMI KONGFACILITY TYPE:
740
ADDRESS:248 SOUTH MARIPOSA AVENUETELEPHONE:
(213) 389-7760
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 6CENSUS: 4DATE:
07/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Eunmi Kong, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:56 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Annual Required visit to the above facility. LPA was met by Eunmi Kong, Administrator and the purpose of today’s visit was explained.

The facility is licensed to serve (6) non-ambulatory residents ages 60 and above and hospice waiver for (2). There are currently (0) residents on hospice.

There are currently (4) residents in the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:



1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted an a current Infection Control Plan.

2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.

2) PHYSICAL PLANT

The facility consists of 4 resident bedrooms, 4 bathrooms (1 bathroom is for visitor use), kitchen, family hall with a prayer room and recreation area, dining room, laundry room located inside the kitchen area. Adequate linen and personal hygiene supplies were observed. Medications were centrally stored, locked and inaccessible to residents in care. Auditory device alarms are operational. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. The outdoor area has a shaped area and seating. Water temperature was tested between 119.1 – 129.3 degrees F which is not within the required range of 105.0 -120.0 degrees F. (continued on 9099C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/21/2025 11:51 AM - It Cannot Be Edited


Created By: Alberto Lopez On 07/21/2025 at 11:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water temperature was measured at 119.1 - 128.3 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2025
Plan of Correction
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Administrator will adjust the water temperature and keep a log for three (3) days and send to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2025


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: 07/21/2025
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(continued from 809)

4. Staffing: The facility has sufficient staff, and the night supervision staff have current CPR/first aid certification.

5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All staff have required ongoing training. Administrator Eunmi Kong Certificate expires 11/10/2025


6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/Appraisal Needs & Services Plan.
7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster are posted at facility. Visiting hours are included in the admission agreement.
8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
9. Food Service: The kitchen was inspected and did have sufficient supply of 2-day perishable & 7-day non-perishable food. The kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. Pesticides and cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents.
10. Incidental Medical and Dental: Medication is centrally stored and locked in the medication cabinet near the kitchen. Four (4) centrally stored resident medications were reviewed, which contained 30-day supply of medications. All medications are administered according to physician’s orders. Two (2) residents PRN medications did not have labels.
Disaster preparedness: The last fire drill was conducted on 06/16/2025. The facility has an Emergency Disaster Plan posted at the facility.
12. Resident with Special Health Needs: No residents receive home health services. No residents are currently on postural support. Individual Service Plans and Appraisals are on file.

Deficiency observed during today’s visit. Technical advisory issued. An exit interview was held. A copy of this report, and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC809 (FAS) - (06/04)
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