198603330-5-16-2024-28-AS-EIRA-D5BSTZ-20240516141021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603330
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:10:26 PM

Document Has Been Signed on 05/16/2024 02:10 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:	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: 68	DATE:	05/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Steve Kim		TIME COMPLETED:	02:15 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 (LPA) Elizabeth Irra conducted an annual inspection visit. LPA was allowed entry by Joan Baek. LPA discussed the purpose of today’s visit. Ms. Kim (Manager) arrived at approximately 9:35 A.M.. Steve Kim (Administrator) arrived at approximately 9:40 A.M.. This facility is approved for (32) ambulatory and (40) non-ambulatory clients (6) of which may be bedridden and (10) of which may be under hospice. Total capacity is: 72. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility does has an Infection Control Plan in place. Operational Requirements: Facility is adhering to the operational requirements. Physical Plant & Environment Safety: LPA toured facility grounds. Fire alarms and Carbon Monoxide detectors were observed. Fire extinguishers are located throughout the property and appeared to be full (last serviced 12/2023). Signal system observed. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: 112.0* in room #110, 115.0* in room #114, 108.0* in room #208 and 113.5* in room #222 Bathrooms had non-skid surfaces and grab bars. Staffing: Facility is adhering to staffing requirements. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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: GARDEN SILVER TOWN	FACILITY NUMBER: 198603330
	VISIT DATE: 05/16/2024

NARRATIVE

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Resident Rights-Information: Resident rights are posted and included in Resident files.

Planned Activities: Activity schedule is posted.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #7 (R-7). Resident files are maintained at the facility. Resident files have the required documents

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.

Residents with Special Health Needs:
Facility is adhering to residents with special health needs.

Health Related Services/Incidental Medical Services: The medications are stored and locked inside the medication room.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to Steve Kim.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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