198603330-6-12-2020-28-AS-PRIS-BQHQ2H-20200612114709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603330
Report Date: 06/11/2020
Date Signed: 06/12/2020 11:47:21 AM

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:	GARDEN SILVER TOWN		FACILITY NUMBER:	198603330
ADMINISTRATOR:	KIM, STEVE		FACILITY TYPE:	740
ADDRESS:	2830 FRANCIS AVE		TELEPHONE:	(213) 384-7305
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90005
CAPACITY:	72	CENSUS: 62	DATE:	06/11/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Steve Kim, Applicant/Administrator		TIME COMPLETED:	04:30 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 Analysts (LPAs) Patricia Rivas initiated an announced tele-visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's tele-visit was a virtual Zoom tele-visit. Licensee Steve Kim was present during the Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) for an initial application of an Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. The facility has a Dementia Care Plan, and auditory alarms on gates leading to the outside. The requested capacity is for Seventy-Two (72) residents (34)-non-ambulatory residents, and six (6) bedridden resident. Bedrooms #101-06 are for bed ridden residents. Bedroom 100, 107-114 are for non ambulatory residents . Dementia residents only on the first floor. Structure: Facility is a two story building consisting of 15 bedrooms downstairs all of which can have two residents; 24 bedrooms upstairs all of which can have two residents. Each bedroom has it's own bathroom. On the first floor there is an office, lobby/activity area, dining room and kitchen and the main court yard for resident use.The second floor has a sitting/library area also has exercise equipment. There is a balcony directly above the activity area with a rail which is over 4 feet. There is a converted garage referred to as the basement that is locked and inaccessible and contains the utility equipment. Bedroom Clients: Bedrooms are equipped , night-stand, chair, lamp, and overhead lightning. Signal System was operational. Bathrooms: Have a working toilet, wash basin, and bathtub, hand rails, non skid mats. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Adequate supply of linens are stored in bedroom closets. Applicant ordered mattress pads during visit. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Facility has a land line telephone. Food Service: Dishes, cups, and chopsticks are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen, and consists of the following: 2 day perishables, and 7 day non-perishables. Applicant reports they have meals catered . ***See LIC 809C for continuation of report.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: (323) 213-1135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN SILVER TOWN	FACILITY NUMBER: 198603330
	VISIT DATE: 06/11/2020

NARRATIVE

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Smoke Detectors: There are smoke detectors located in all bedrooms. The facility has a sprinkler system in place. Carbon monoxide detector is in the kitchen and was found to be operational. Appliances: Oven, microwave, dishwasher and dryer are in working condition. The facility is having all residents clothing laundered by third parties at no cost to them. There is no washer in the facility. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. Water Temperature: Hot water was tested in various rooms and measured between 109 degrees Fahrenheit to 113 Degrees Fahrenheit. . Medication Designated centrally stored medications are stored in the office. Clients & Staff Files: In the office and medication room.
Applicant will not handle cash resources of residents. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 04/16/20 for 32 ambulatory, 34 non-ambulatory, and one 6 bedridden with no delayed egress or locked perimeter. Component III: Component III was conducted.

An exit interview was conducted and a copy of this report has emailed to applicant for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: (323) 213-1135
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

LIC809 (FAS) - (06/04)

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