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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603169
Report Date: 07/01/2020
Date Signed: 07/01/2020 05:11:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOPE HOME CARE FOR ELDERLYFACILITY NUMBER:
198603169
ADMINISTRATOR:KIM, JUNG HYUNFACILITY TYPE:
740
ADDRESS:23916 HIGHLAND VALLEY RDTELEPHONE:
(909) 217-2011
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 2DATE:
07/01/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Jung Hyun Kim, Licensee/AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ren’ee Arterberry conducted a Case Management Visit pertaining to Complaint #: 28-AS-20200625095226. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures today's Case Management Visit was conducted telephonically with the Licensee/Administrator Jung Hyun Kim, the facility administrator of HOPE HOME CARE FOR ELDERLY.

During the course of the investigation pertaining to a resident who shall be referred to as, R1, it was determined that the administrator failed:
  • to ensure the file for R1 was complete.
  • to provide an Unusual Incident Report (SIR) to CCL
  • to revise the file documents for R1. The administrator state that a change in health condition was noted but failed to provide revised file documents to support the change in health condition.


Deficiencies cited under California Code of Regulations Title 22

Hopr Home Care

An exit Interview was conducted via telephone with the administrator and a hardcopy was provided via email for signature. Signatures on hardcopies.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2020
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOPE HOME CARE FOR ELDERLY
FACILITY NUMBER: 198603169
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2020
Section Cited

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Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidence by, when the LPA requested certain file documents the administrator was unable to provide the documents.
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the POC Date. Email address is: Renee.Arterberry@dss.ca.gov.
Type B
07/17/2020
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of
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any of the events specified below. This requirement was not met as evidence by, the administrator state that R1 refused medications and was transported to the hospital and the administrator failed to report/submit to CCL a written SIR to report the incidents as required per regulations.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOPE HOME CARE FOR ELDERLY
FACILITY NUMBER: 198603169
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2020
Section Cited

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OBSERVATION OF THE RESIDENT: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or
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a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence by the licensee statement that she observed a change of health condition that was not noted in the resident's file as required. The resident have refused medications.
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 The written statement shall be sent to CCL to the attention of LPA Arterberry by the POC Date.

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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3