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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603169
Report Date: 06/30/2023
Date Signed: 06/30/2023 04:43:13 PM


Document Has Been Signed on 06/30/2023 04:43 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 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: 6DATE:
06/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Jung KimTIME COMPLETED:
04:42 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit on 6/30/23, regarding an incident that occurred at Happy Home Care for Elderly and is owned by Licensee Jung Kim. LPA Ramirez gained entry into the facility at 10:25 am. LPA Ramirez was greeted by Licensee/Administrator Jung Kim and LPA explained the purpose of the visit. The facility is licensed to serve residents 60 years old and older and has a fire clearance for four (4) ambulatory and two (2) non-ambulatory. The facility is currently approved for six (6) hospice residents. LPA Ramirez and Licensee Kim conducted physical plant tour at 10:33 am

Case Management Findings:

· Minimum of two (2) day supply of perishable food was not observed on the premises.

· Resident Room #1 was observed to be shared. LPA Ramirez observed a 7ft x 14ft beige room divider and a white door that led into a makeshift spare bedroom. LPA Ramirez observed a twin sized framed bed with one (1) mattress, one (1) pillow and five (5) drawers attached to the bottom of the frame, and two standing dressers. No linen was observed on the mattress. LPA Ramirez observed an empty, clear, three (3) drawer plastic cubby located next to bed. LPA Ramirez observed a sliding door that leads to the backyard from this makeshift spare room. Entry into this makeshift spare room can be accessed through resident room#1 door entry and sliding door entry from backyard. Per Licensee Kim, former staff would stay in this area but, the area is now being utilized by the residents currently occupying bedroom#1 as an extra area to rest. LPA Ramirez observed facility sketch plan posed in dining room area. Facility sketch does not reflect observations made by LPA Ramirez in resident bedroom #1. Facility sketch also states “two (2) non-ambulatory” and does not reflect room would be utilized for staff or as a spare room for residents. This licensing agency did not receive prior request or notification of construction or alteration to facility.

SEE 809-C for continuation

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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 5


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: 06/30/2023
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· LPA Ramirez observed auditory devices in “OFF” mode and not operable during visit. LPA Ramirez advised staff and licensee to keep auditory devices in “ON” mode. LPA Ramirez observed auditory device on outside of dining room sliding door to be secured with clear tape. Staff later secured auditory device according to it’s original design.

· Copy of Certificate of liability insurance provided to LPA Ramirez on 6/30/23 does not meet liability limits.

Exit interview is being conducted with Licensee Jung Kim and a copy of this report, 809-D, and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 06/30/2023 04:43 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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2023
Section Cited
HSC
1569.605

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1569.605
Liability insurance; coverage requirements
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidence by:
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Licensee agreed to submit plan by 7/01/23 to address liability insurance. Proof of liability insurance that meets liability limits per HSC 1569.605 must be submitted to LPA by 7/10/23.
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Copy of Certificate of liability insurance provided to LPA Ramirez on 6/30/23 does not meet liability limits.
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Type A
07/01/2023
Section Cited
CCR87555(26)

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 87555
General Food Service Requirements

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidence by:
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Minimum of two (2) day supply of perishable food was not observed on the premises.
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Licensee will maintain nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. Licensee will provide LPA Ramirez receipt of perishable food supply for a minimum of two days for six residents. Must be submitted via email to LPA by 7/1/23.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 06/30/2023 04:43 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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2023
Section Cited
CCR
87705(j)

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87705
Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidence by:


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Licensee will develop a plan to re-train staff on the importance of keeping auditory devices to "ON" mode. Proof of staff receiving training must be submitted to LPA Ramirez by 7/7/23 via email.
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• LPA Ramirez observed auditory devices in “OFF” mode and not operable during visit. LPA Ramirez advised staff and licensee to keep auditory devices in “ON” mode. LPA Ramirez observed auditory device on outside of dining room sliding door to be secured with clear tape. Staff later secured auditory device according to it’s original design.
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Type B
07/14/2023
Section Cited
CCR87305(a)(b)

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87305
Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

(b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidence by:
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Licensee agreed to contact local code enforcement to obtain permit or inspection to ensure divider wall is safe and does not pose a potential risk to residents in care, staff or visitors. Licensee agreed to take down divider wall if permit or inspection could not be obatined by 7/14/23. Proof must be submitted to LPA Ramirez by 7/14/23 via email. Licensee agreed to refrain from using this makeshift room until code enforcement or this licensing agency grants approval.
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Resident Room #1 was observed to be shared. LPA Ramirez observed a 7ft x 14ft beige room divider and a white door that led into a makeshift spare bedroom. Facility sketch also states “ two (2) non-ambulatory” and does not reflect room would be utilized for staff or as a spare room for residents.
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/30/2023 04:43 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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
87307(C)

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87307
Personal Accommodations and Services

(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidence by:
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Liensee will certify in writing to this licensing agency, that residnet bedroom #1 will not be used as a passageway to another room. Proof must be submitted to LPA Ramirez by 7/7/23 via email.
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LPA Ramirez observed a sliding door that leads to the backyard from this makeshift spare room. Entry into this makeshift spare room can be accessed through resident room#1 door entry and sliding door entry from backyard. Per Licensee Kim, former staff would stay in this area but, the area is now being utilized by the residents currently occupying bedroom#1 as an extra area to rest.
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5