<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603414
Report Date: 01/21/2021
Date Signed: 01/21/2021 04:20:17 PM

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:ELIMCARE WELLNESSFACILITY NUMBER:
198603414
ADMINISTRATOR:KIM, HENRYFACILITY TYPE:
740
ADDRESS:4669 OLYMPIC BLVDTELEPHONE:
(213) 550-7898
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:6CENSUS: 0DATE:
01/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Henry KimTIME 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 Analyst (LPA) Alma Gonzalez conducted an announced Pre-Licensing virtually for the facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, todays Pre-Licensing visit was conducted virtually via Facetime with Administrator Henry Kim.

The purpose of the visit was to inspect the physical plant for licensing of the facility and to conduct the Component III orientation.

The applicant will serve 6 residents ages 59 and older and fire clearance was approved for 6 ambulatory residents. Fire Clearance was approved on 12/10/20.

LPA and Administrator conducted a tour of the the facility. Facility physical plant consists of a one story building structure that consists the following:

Facility consists of 6 rooms, 1 lounge/ living room, kitchen, dining room and laundry area, 4 bathrooms. Physical plant inside and outside is clean, sanitary and in good repair.

Inspection of facility revealed the following:

Locked cabinet for medications and facility files.
Passageway and doors are not blocked or obstructed.
Windows screens are in good repair.
All Beds have the required linen/supplies: pillowcase, mattress pads, fitted sheet, blanket and bedspreads.
All Mattress and bedsprings are in good repair.
Residents furniture: one chair, night stand, adequate lighting for each client, and adequate closet and drawer space.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
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 2
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: ELIMCARE WELLNESS
FACILITY NUMBER: 198603414
VISIT DATE: 01/21/2021
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
Water temperature met Title 22 Regulations measuring between 105-120 F. (120)
Refrigerators, stove, sinks, toilets and showers operate properly.
Cupboards, freezer, stove, microwave, refrigerator and counters are clean.
Freezer is 0 degrees Fahrenheit.
Sufficient amount of personal hygiene supplies available for clients.
There was a 7 day supply of non-perishables available and a 2 day supply of perishables available.
Resident records inaccessible to unauthorized persons.
Emergency disaster plan, personal rights and complaint procedures are posted.
First Aid Kit and manual is complete and readily available.
Smoke detectors and carbon monoxide detector operate properly and fire extinguishers are properly charged.
Working washers and dryers.
Working telephone.
There are no bodies of water located on the premises.
Adequate seating in common areas for licensed capacity.
Furniture in all facility rooms appropriate, clean and in good repair.
There is an outdoor activity space/ patio with a shaded area and furnished for outdoor use.


Component III: Conducted during the Pre-Licensing inspection, information provided about how to operate the facility within substantial compliance and all required documents for Licensing were discussed.

During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations.

Tele-inspection was completed and an exit interview was conducted. Copy of this report was emailed to Administrator Henry Kim.

Facility met the physical plant requirements as required per California Code of Regulations Title 22 Division 6.



LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2