198602554-5-15-2023-28-AS-RORN-CSCNFS-20230531102559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602554
Report Date: 04/04/2023
Date Signed: 05/15/2023 09:47:33 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/29/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230329131939

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: 6	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Seong Soo Han		TIME COMPLETED:	11:45 PM

ALLEGATION(S):

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Staff left the residents unattended while in care

INVESTIGATION FINDINGS:

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*****This report serves as an amendment and supersedes the original complaint investigation report dated 4/4/2023. The reason for amendment is to add additional information on LIC9099 and LIC9099C and make corrections on LIC9099D. Investigation finding remain the same. ******

Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Administrator Seong Soo Han who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: LPA interviewed administrator and three staff (S1-S3) and six residents (R1-R6) and obtained copy of R1's documents including face sheet, pre-appraisal, and physician report.

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230329131939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/04/2023

NARRATIVE

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The investigation revealed of the following: Allegation "Staff left the residents unattended while in care." LPA interviewed residents and they all feel safe living in the facility and the staff treated them good. LPA interviewed staff and admitted the staff did leave the residents unattended while in care. Administrator reported the facility usually have three staff work in the facility after dinner but on 03/28/23, the administrator and wife went out for dinner. S1 was the only staff on duty at that time yet she left the facility for approximately 15 minutes leaving 6 residents unattended including at least one that was bedridden. One of the residents began to bang on the window asking for help resulting in the police being called. Firefighters were called to the location and made entry through a window. Although law enforcement did not observe any injuries on the residents in placement, the caregiver was arrested when she returned to the facility for neglect/absence of supervision and will be appearing in court at a later date.

Based on LPA’s interviews, and review of documentation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to the facility staff left the residents for absence of supervision. Refer to LIC 421IM***

An exit interview conducted, a copy of the report and appeal right was provided to the administrator Seong Soo Han.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230329131939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:	1 2 3 4 5 6 7	The administrator will provide to training staff about the regualtion and send the training log to LPA by POC due date.
	8 9 10 11 12 13 14	(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The requirement was not met as evidenced : By LPA's interview, the staff let residents unattended which posed an immediate risk to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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