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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320114
Report Date: 10/03/2024
Date Signed: 10/03/2024 06:56:55 PM

Document Has Been Signed on 10/03/2024 06:56 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SUNCOAST SENIOR LIVING AT LONG BEACHFACILITY NUMBER:
198320114
ADMINISTRATOR/
DIRECTOR:		KIM, KI HWANFACILITY TYPE:
740
ADDRESS:2520 GONDAR AVETELEPHONE:
(718) 683-1000
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:Ki Hwan KimTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On October 3, 2024 Licensing Program Manager (LPM) Eva Alvarez and Licensing Program Analyst (LPA) Deborah Lee conducted a complaint visit at this facility. During this visit deficiencies were observed. LPA and LPM met with Licensee Tim Kim during this visit.

During LPA's visit LPA Lee was unable to verify a criminal record clearance and association for Staff #2 (S#2). LPA found S#2 has no record of having obtained a criminal record clearance and is not currently associated to this facility. LPA found Staff #1(S#1) obtained a criminal clearance; however, is not associated to this facility. Licensee Kim stated, attempts have made to associate S#1 through the CCL Guardian portal. Licensee Kim stated he has been unable to associate S#1 through the Guardian portal and has communicated via e-mail with the Care Provider Management Branch. The Licensee has provided a completed LIC 9182 criminal background clearance transfer request to LPM Alvarez. The LIC 9182 will be processed by the Regional Office on 10/4/2024 to associate S#1.

Title 22, Division Chapter 1, Article 03. is being cited, please see attached LIC809D.

An exit was conducted, and plans of correction was developed with the administrator. A copy of this report and the appeals rights was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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
Document Has Been Signed on 10/03/2024 06:56 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Deborah Lee On 10/03/2024 at 01:42 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH
FACILITY NUMBER: 198320114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/04/2024
Section Cited
CCR
87355(e)(1)

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 All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility.ottain a California clearance.
This requirement was not met as evidenced by:
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LIcensee will ensure that S2 obtains a criminal records clearance and association to facility prior to working in the facility. Licensee will ensure S2 shall not work in the facility until a clearance is obtain.
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LPA was unable to to verify S2 criminal clearance or association to facility. Which poses an immediate health & safety risk.
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Violation of Section 87355(e) will result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation for a maximum of 5 days by the Department. Civil penalties have been assesed for th amount of $500.00.

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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.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Deborah Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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