198603330-6-2-2025-28-AS-MCOA-DH9THD-20250602144435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603330
Report Date: 06/02/2025
Date Signed: 06/02/2025 04:53:35 PM

Document Has Been Signed on 06/02/2025 04:53 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GARDEN SILVER TOWN		FACILITY NUMBER:	198603330
ADMINISTRATOR/ DIRECTOR:	KIM, STEVE		FACILITY TYPE:	740
ADDRESS:	2830 FRANCIS AVE		TELEPHONE:	(213) 384-7305
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90005
CAPACITY: 72	TOTAL ENROLLED CHILDREN: 0	CENSUS: 67	DATE:	06/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:57 AM
MET WITH:	Steve Kim, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Mayra Cota conducted an unannounced required annual visit. LPA met with Steve Kim, Administrator and explained the reason for the visit.

The facility is licensed to serve adults in the age range of (60) and over; approved for (32) ambulatory only and approved for (40) non-ambulatory, of which (6) may be bed ridden. Facility is approved for Hospice waiver for (10). The facility is operating within the scope of its license.

The facility is a two story building located in a residential area of Los Angeles and contains the following:

Thirty-nine (39) Bedrooms, (42) bathrooms, kitchen, dining room, library, TV room, activity room/exercise area, main office, medication room with locked storage cabinet for medications and sharps, (5) storage closets for linen, cleaning supplies and dry food, (2) laundry rooms and a center courtyard with shaded area and seating for resident use.

LPA observed the following during today's visit:

Facility was observed to be clean and walkways were clear of obstructions and debris.

Resident bedrooms have the required furniture such as bed frames, dressers, lamps/overhead lighting, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and and beds with adaptive handrails have physician order documentation on file.

***Continues on LIC 809-C

Wei Siew Ho	TELEPHONE: (323) 981-3969
Mayra Cota	TELEPHONE: (323) 980-4934
	DATE: 06/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 06/02/2025 04:53 PM - It Cannot Be Edited

Created By: Mayra Cota On 06/02/2025 at 01:17 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN SILVER TOWN	FACILITY NUMBER: 198603330
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in due to rodent droppings observed by LPA in storage cabinets during visit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2025
	Plan of Correction
1 2 3 4	Licensee will send work order for exterminator's assessment of the locations where rodent droppings were observed and treatement service for the facility's dining room and where additionally needed. Licensee will send photos to LPA of the dining area cabinets cleared out of clutter and rodent droppings by POC due date.

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.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (323) 981-3969

	Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (323) 980-4934

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2025 04:53 PM - It Cannot Be Edited

Created By: Mayra Cota On 06/02/2025 at 01:17 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN SILVER TOWN	FACILITY NUMBER: 198603330
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(a)(2)(A)

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observationn, the licensee did not comply with the section cited above in that storage cabinets were observed to have grease stains on the exterior and inside the storage area which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2025
	Plan of Correction
1 2 3 4	Licensee will declutter kitchen cabinets and clean grease and other mildew inside and out. Licensee will send LPA photos of work completed as POC proof.

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.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (323) 981-3969

	Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (323) 980-4934

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN SILVER TOWN	FACILITY NUMBER: 198603330
	VISIT DATE: 06/02/2025

NARRATIVE

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Resident bedrooms are equipped with call buttons in the bathroom and at bedside. During visit, call buttons were tested and observed operable. Resident rooms with individuals requiring oxygen have the required postings.

Six (6) resident bathrooms were observed clean and sanitary. Bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. The water temperature was tested in resident bathrooms and measured within the required 105 - 120 degrees F.

Kitchen was inspected, however, storage cabinets were observed to have grease stains on the exterior and inside the storage area. Appliances were observed to be clean and working properly. Food inside refrigerators was observed to be properly stored and dated. Sharps are kept locked in a kitchen drawer and are inaccessible to clients. Sufficient supply of 2 day perishable and 7 day non-perishable food was observed and additional emergency food supply was observed in the dry food storage room. Food in the refrigerators and dry food storage room is labeled and kept within expiration limits. The dining area has enough seating for residents and furniture was observed to be in good repair. Rodent droppings were observed in storage cabinets during visit. Facility has a contract with outside vendor for food delivery. Facility manages food preparation and distribution to residents. Menus were observed posted in the dining area.

The center courtyard was inspected and observed to be clean. Shaded areas were observed and outdoor furniture is in good repair. Garden is maintained and free of dry plants and fallen foliage.

Resident medications and MARs were reviewed and found to be properly dispensed per physician orders and documented accordingly.

Eight (8) resident and (6) staff files were reviewed and contained all proper documentation.

Fire extinguishers were observed throughout the facility and were charged and last inspected on 12/20/24. Fire alarm system was last inspected on 6/1/25 and the facility conducted their last emergency drill on 4/25/25. Facility is equipped with a sprinkler system and resident rooms are equipped with combination smoke and carbon monoxide detectors which were tested in (4) resident bedrooms and were working properly.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Mayra Cota	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN SILVER TOWN	FACILITY NUMBER: 198603330
	VISIT DATE: 06/02/2025

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 26 27 28 29 30 31 32	Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies are cited today (see LIC 809-D). Exit interview conducted with Steve Kim, Administrator and a copy of the report and Appeal Rights were provided during visit.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Mayra Cota	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025

LIC809 (FAS) - (06/04)

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