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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320114
Report Date: 08/14/2022
Date Signed: 08/14/2022 06:34:50 PM

Document Has Been Signed on 08/14/2022 06:34 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SUNCOAST SENIOR LIVING AT LONG BEACHFACILITY NUMBER:
198320114
ADMINISTRATOR:KIM, KI HWANFACILITY TYPE:
740
ADDRESS:2520 GONDAR AVETELEPHONE:
(718) 683-1000
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 1DATE:
08/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Ki Hwan Kim TIME COMPLETED:
06:00 PM
NARRATIVE
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On 08/14/22, Licensing Program Analyst (LPA) Ernand Dabuet initiated a Case Management visit. LPA was met by Ki Hwan Kim the licensee/administrator and explained the purpose of today’s visit.

LPA toured the physical plant in association with the required annual inspection on 08/14/22. LPA identified at 1:20 pm resident #1 (R1) who is not on hospice care had full bed rails which is prohibited according to Postural Supports Title 22 Section 87608. The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

Deficiencies are issued and an exit interview is conducted with Ki Hwan Kim. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2022
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 08/14/2022 06:34 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/14/2022 at 03:30 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
, 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: 08/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2022
Section Cited
CCR
87355(c)

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87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2 )Knowledge of and ability to conform to the applicable laws, rules and regulations.

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The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 08/26/22
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.
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Type B
08/26/2022
Section Cited
CCR87608(B)

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87608 - Postural Supports (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Licensee will adhere to the regulations 87705 and will conduct a fire/earthquake drill as required. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/26/22
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This requirement is not met as evidence by:
Based on interview with administrator, Licensee failed to show proof for full bed rails for (R1) who is not a hospice reisdent. This violation possess a potential Health and Safety risk to residents in care.
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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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2022


LIC809 (FAS) - (06/04)
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