198603169-11-30-2022-28-AS-BPEA-CLNVQT-20221130153851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603169
Report Date: 11/30/2022
Date Signed: 11/30/2022 03:38:56 PM

Document Has Been Signed on 11/30/2022 03:38 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: 5	DATE:	11/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Administrator, Jung Hyun Kim		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) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Pena was greeted by the caregiver Deuk Kong and was covid screened upon entry. At 1:51pm, Administrator, Jung Hyun Kim arrived and LPA discussed the purpose of today's visit. The facility is licensed to serve elderly residents, age range 60 and over. It is approved for capacity of four (4) ambulatory and two (2) non ambulatory and hospice waiver for six (6) residents. There are currently five (5) residents who are livin gin the facility, two (2) of which are non ambulatory. This single-story home contains four (4) bedrooms, three (3) bathrooms, a small office next to the dining room, a living room/activity area, dining room, kitchen, backyard, and attached garage. Annual fees are current. LPA and the Administrator toured the facility and the following was observed/inspected: The facility had a universal entrance screening area including a sign-in sheet, thermometer, and hand sanitizer. COVID-19 signage was placed in several areas including entrance and common areas. Facility maintain a 30-day supply of PPE including N-95, surgical masks, hand sanitizers, gloves, gowns, and face shields. Staff wore face masks throughout their shift and furniture was spaced for physical distancing. Facility currently has at least a 30-day supply of PPEs. At 2:15pm, kitchen was inspected and LPA observed that there was a sufficient supply of 2-day perishable foods and 7-day non-perishable foods. All kitchen appliances are clean and in working order. Cleaning solutions and sharps were locked in the cabinets and inaccessible to the residents. Hot water temperature was measured and were within the required 105-120 degrees F. At 2pm, bathroom #1's hot water temperature read at 113.2 deg. F, bathroom # 2 read at 105.2 deg. F and bathroom #3 read at 106.5 deg. F and kitchen was measured at 112.2 deg. F.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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: 11/30/2022

NARRATIVE

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All resident bedrooms contained required furniture including bed, dresser, night stand, trash bins with lid, lamp, and chair.
Attached garage was inspected and used for storage and laundry area.
Medications were locked and centrally stored. Medications were given as prescribed.
Smoke detectors/carbon monoxide detectors were present and operable.
Backyard was inspected and Indoor/outdoor passageways were free from obstruction. The backyard has a shaded area and sitting area. The activity area and backyard have been designated as the visitor area during the COVID-19 pandemic.
Exit doors have auditory devices that were operating at the time of the visit.
There is a fire extinguisher located in the dining room/kitchen and observed to be fully charged and recently purchased on 7/09/2022.
There are no firearms being stored at this location. There are no cameras or bodies of water in the facility.
Resident files were inspected, and emergency contact information and health screenings were up to date for all residents.
Staff files were inspected and contained the required health screenings, criminal record clearances, and training. Administrator certificate expires on 5/15/2024.
Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress.
Infection Control Plan was submitted to CCLD in May 2022.

No deficiencies were cited. An exit interview was conducted and a copy of this report and appeal rights were provided to the Administrator, Jung Hun Kim.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC809 (FAS) - (06/04)

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