198602554-9-9-2024-28-AS-THEA-D8XRRR-20240909131533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602554
Report Date: 09/09/2024
Date Signed: 09/09/2024 01:15:39 PM

Document Has Been Signed on 09/09/2024 01:15 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
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: 6	DATE:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Phyllis Lee - Assistant Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Phyllis Lee - Assistant Administrator and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60 and over (dementia approved), with a Hospice waiver for 2. There are no Residents with Hospice services at the moment.

The facility is a single-story home located in Lakewood, Ca. A tour of the facility includes: 4 resident bedrooms, 1 bathroom, living room, kitchen, laundry area, front yard, and backyard. There is a separate area for staff that includes bedroom, living room, there is also 1 staff bedroom and Staff office area with surplus of canned foods/refrigerated food.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:

Infection Control: Staff are cleaning and disinfecting throughout the day and have an Infection Control Plan maintained at the facility.
Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance.
Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
(continued on LIC809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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: 09/09/2024

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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.
Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Seong Soo Han maintains a valid Administrator Certificate that expires on 3/2/2026.
Resident Records-Incident Reports: Resident files are kept in a secure location (within staff office area) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files, there will be a citation as 1 out of 4 files reviewed was missing an updated needs and service plan, last updated plan was when resident was admitted in 2017, details will be found in the LIC809-D
Residents Rights-Information: Residents are provided with telephone and internet at the facility.
Planned Activities: Facility provides a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 6 residents’ medications and there were no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The facility did not have record of the last Fire/Earthquake/Emergency Disaster Drill, citation will be issued and details will be found on LIC809-D.
Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. Residents with half-bed rails had a prescription for them within their file.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit will be detailed in the LIC809-D.

Exit interview held and a copy of the report and appeal rights were provided to Phyllis Lee.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/09/2024 01:15 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 as there was no record found for the last fire/emergency drill, Assistant Administrator stated that they have not conducted a drill in quite some time, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to conduct a fire/emergency drill and review the above regualtion in its entirety. A copy of the drill and the signed LIC9098 (which identifies that the regulation was reviewed and moving forward drills will be conducted per requirement) shall be emailed to LPA by POC due date. (tena.herrera@dss.ca.gov)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. 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 as 1 out of 4 client files reviewed during todays visit did not have an updated needs and service appraisal done since admission into the facility in 2017, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to complete an updated need and service appraisal per the requirement and send a copy to LPA via email by POC due date. Additionally, Licensee/Administrator shall review the above regulation in its entirety and complete the LIC9098 provided during todays visit and email the signed form to LPA by POC due date (a signed LIC 9098 will identify that the regulation was reviewed and moving all clients will have thier appraisals completed on a regular basis). - tena.herrera@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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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