<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602554
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:43:56 AM


Document Has Been Signed on 08/22/2023 10:43 AM - 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 CAREFACILITY NUMBER:
198602554
ADMINISTRATOR:HAN, SEONG SOOFACILITY TYPE:
740
ADDRESS:20621 SEINE AVENUETELEPHONE:
(714) 504-4257
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:6CENSUS: 6DATE:
08/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Phyllis LeeTIME COMPLETED:
11:00 AM
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) Wong conducted an unannounced case management visit to the facility. The purpose of today's visit was to serve the Order of Licensee/Administrator of Immediate Exclusion from facility for Staff#1 (S1). An investigation by California Department of Social Services was concluded and it was determined that S1 violated California Code of Regulation Title 22 for personal rights.

On today's visit, LPA met with Administrator Phyllis Lee and explained the reason of the visit. Administrator provided with copies of the Order of Licensee of Immediate Exclusion and Order to Individual for Immediate Exclusion and Government Code 11522.

Exit Interview held. A copy of the report was provided to Administrator Phyllis Lee.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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 1