198320114-9-1-2023-11-AS-SLEO-CV9VAE-20230901161548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320114
Report Date: 09/01/2023
Date Signed: 09/01/2023 04:15:55 PM

Document Has Been Signed on 09/01/2023 04:15 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNCOAST SENIOR LIVING AT LONG BEACH		FACILITY NUMBER:	198320114
ADMINISTRATOR:	KIM, KI HWAN		FACILITY TYPE:	740
ADDRESS:	2520 GONDAR AVE		TELEPHONE:	(718) 683-1000
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 5	DATE:	09/01/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:43 AM
MET WITH:	Ki H. Kim		TIME COMPLETED:	04:30 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	On 09/1/2023, Licensing Program Manager (LPM) Ulysses Coronel & Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Case Management - Annual Continuation. LPM & LPA met with administrator Ki Hwan Kim and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for (1) hospice resident. There are currently five (5) residents in care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, six (6) bathrooms, a living area, a dining area, a kitchen, and outside patio area. LPM & LPA toured the physical plant. During todays visit LPM & LPA reviewed the Mitigation Plan, Emergency Disaster Plan, Program Plan, five (5) resident records and three (3) staff records. Deficiencies were cited and civil penalties were assessed. An exit interview was conducted and plans of corrections were developed. A copy of this report and appeals rights were provided to Ki H. Kim, Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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 10/05/2023 02:52 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/05/2023 02:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in During todays record review LPA did not observe health screeining report (LIC503) for S1, S2, & S3 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	The licensee agrees to obtain health screening reports LIC503 for S1, S2, & S3.Proof of correction will be emailed to socorro.leandro@dss.ca.gov.

Type B

Section Cited

CCR

87412(a)(13)(B)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review. The licensee did not comply with the section cited above, LPA did not observe a criminal record clearance for S3.which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	During todays visit the administrator removed S3 from work schedule. The administrator agreed to obtain S3's criminal record clearance prior to allowing S3 back to work. Proof of correction will be emailed to socorro.leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/05/2023 02:59 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/05/2023 02:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above during todays record review LPA observed S1 first aid certificate expired on 11/2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	The licensee agrees to obtain first aid certificate for S1. Proof of correction will be emailed to socorro.leandro@dsss.ca.gov.

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review) the licensee did not comply with the section cited above during todays visit LPA did not observe records of S1, S2 and S3' initial 10-hour trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	The licensee agrees to maintain records of S1, S2 and S3' initial 10-hour trainings. Proof of correction will be emailed to socorro.leandro@dsss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/05/2023 03:03 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/05/2023 03:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH	FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions


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

Type B

Section Cited

CCR

87616(b)(1)

Exceptions for Health Conditions

(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, during todays record review LPA did not observe physian reports (LIC602A) for R1, R4, & R5. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	The licensee agrees to obtain physian reports (LIC602A) for R1, R4, & R5. Proof of correction will be emailed to socorro.leandro@dsss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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