198602554-11-4-2022-28-AS-LMOA-CKUQLE-20221104121551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602554
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:16:07 PM

Document Has Been Signed on 11/04/2022 12:16 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	KOREAN SENIOR CARE		FACILITY NUMBER:	198602554
ADMINISTRATOR:	HAN, SEONG SOO		FACILITY TYPE:	740
ADDRESS:	20621 SEINE AVENUE		TELEPHONE:	(714) 504-4257
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	6	CENSUS: 5	DATE:	11/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Phyllis Lee - Assistant Administrator		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met Phyllis Lee - Assistant Administrator and explained the reason for the visit. The facility is licensed to serve six non-ambulatory residents ages 60 and over and may retain up to two hospice residents. The facility is operating within the scope of its license. The facility is located in a residential area. A tour of the single-story facility included: 4 resident bedrooms, 1 bathroom, living room, kitchen, front yard, and backyard. LPA and Phyllis toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the bathroom and measured at 115.4 degrees F which is within the required 105 - 120 degrees F. The bathroom is clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a living room closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the hallway and it is properly operating. A fire extinguisher was observed in the kitchen and hallway which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Knives are kept locked under the kitchen sink. Cleaning chemicals are kept locked in the living room closet. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard and front yard. There are no bodies of water. Passageways and exits are free of obstruction. (CONTINUED TO LIC 809C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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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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: KOREAN SENIOR CARE	FACILITY NUMBER: 198602554
	VISIT DATE: 11/04/2022

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Residents medication are centrally stored in a locked hallway cabinet. Residents and staff files are centrally stored in the medication cabinet. LPA reviewed medication for 3 of the residents and observed that medications are given as prescribed. The other 2 residents do not have medication prescribed to them. LPA reviewed files for 5 residents and 4 staff and observed no deficiencies. LPA observed administrator certificate for Seong Soo Han - 6042329740 with an expiration date of 03/02/2024.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed.

The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by 01/03/2023.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed. Exit interview held and a copy of the report were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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