198603169-11-13-2023-28-AS-CDCN-CXK2AE-20231113161326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603169
Report Date: 11/13/2023
Date Signed: 11/13/2023 04:14:40 PM

Document Has Been Signed on 11/13/2023 04:14 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:	HOPE HOME CARE FOR ELDERLY		FACILITY NUMBER:	198603169
ADMINISTRATOR:	KIM, JUNG HYUN		FACILITY TYPE:	740
ADDRESS:	23916 HIGHLAND VALLEY RD		TELEPHONE:	(909) 217-2011
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	11/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:56 AM
MET WITH:	Eunice Kim, Licensee		TIME COMPLETED:	04:00 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) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Licensee Eunice Kim and explained the purpose of the visit. The facility is licensed for a capacity of 6 residents, ages 60 and over, of which 2 may be non-ambulatory. There is an approved hospice waiver for 6 residents. LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: Facility staff are using appropriate hand hygiene and wearing gloves while assisting residents when necessary. Staff continue to clean and disinfect daily and more often for high touched surfaces. Facility had submitted the Infection Control Plan. Operational Requirements: The facility accepts or retains residents with dementia. There are currently 4 residents diagnosed with dementia residing at the facility. 2 out of the 6 residents are non-ambulatory. Licensee has the sufficient amount for liability insurance that is required. Physical Plant & Environment Safety: The facility consists of a single story building with 4 resident bedrooms, 3 bathrooms, living room, dining space, kitchen, and attached garage. The backyard has area for gardening and relaxing. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. There are 2 operable carbon monoxide detectors and smoke detectors throughout the facility. The hot water temperature was measured within the required range of 105-120 degrees F. The fireplace is secured by a locked gate. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. The facility purchases meal plans from a food vendor for lunch and dinner.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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: HOPE HOME CARE FOR ELDERLY	FACILITY NUMBER: 198603169
	VISIT DATE: 11/13/2023

NARRATIVE

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Staffing: The facility has sufficient staffing to meet the needs of the residents. Per administrator, there are backup staffing if needed.
Personnel Records-Training: LPA reviewed 4 Staff files. The administrator's certificate expires on 5/15/24. Staff have fingerprint clearance and associated to the facility. All staff have current CPR and First Aid certificates. Licensee provides on-going training to staff.
Resident Records-Incident Reports: LPA reviewed 6 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and Appraisal/Needs and Services Plan. The physician's report for resident #6 with dementia is not current.
Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Incidental Medical & Dental: The medications are centrally stored. LPA reviewed 6 residents' medications and they are being given as prescribed by the physician's orders. Staff assist and transport residents to their doctor, dental, and specialist appointments.
Residents with SHN: Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence.

A deficiency is issued on the LIC809D. Technical assistance are provided as well.
An exit interview was held. A copy of this report along with appeal rights are given to the licensee.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/13/2023 04:14 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: HOPE HOME CARE FOR ELDERLY	FACILITY NUMBER: 198603169
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, 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 in which 1 out of 6 residents' physician's report are past a year of its last exam which poses a potential health and safety risk to residents in care
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	The licensee shall provide an updated physician's report for resident #6 by POC due date 11/30/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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