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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603414
Report Date: 01/26/2022
Date Signed: 01/26/2022 03:58:00 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:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Henry KimTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control Visit to the above facility. LPA was met by Administrator Henry Kim and the purpose of today’s visit was explained.

The facility is licensed to serve 6 residents ages 59 and older all 6 residents will be ambulatory. There are currently zero (0) residents in the facility. The facility physical plant consists of a one story building structure located in a residential area. The facility consists the following: 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.



LPA and Administrator Kim toured the entire facility inside and out. Documents are posted as mandated. Resident bedrooms contain the mandated furniture. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents in a locked cabinet. Food supply was adequate for 2-day perishable and 7-day non-perishable. Hot water temperature is 116 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, All bathrooms have the required grab bars next to toilets and in the shower. Exit, walkways and/or passageways, are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors will be logged and temperatures checked, sanitizer/soap located throughout the facility and additional sanitation supplies are stored in the facility. LPA observed staff wearing masks and keeping 6 ft distance. The facility has a room that will be converted to an

(Continued on LIC809C)
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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: ELIMCARE WELLNESS
FACILITY NUMBER: 198603414
VISIT DATE: 01/26/2022
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isolation room (if needed) and required postings placed throughout the facility. The residents temperatures will be checked and logged once twice a day as well as facility staff. Resident records will be inaccessible to unauthorized persons. 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.

PPE's are enough for 30 days.

According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Henry Kim and a copy of report provided.

SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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