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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603596
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:35:40 PM


Document Has Been Signed on 10/10/2023 02:35 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:LOVE HOME CARE FOR ELDERLYFACILITY NUMBER:
198603596
ADMINISTRATOR:KIM, JUNG HYUNFACILITY TYPE:
740
ADDRESS:22935 HAPPY HOLLOW RDTELEPHONE:
(909) 217-2011
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 0DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Jung "Eunice" Kim, AdministratorTIME COMPLETED:
02:45 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) Cynthia Chan conducted the unannounced annual inspection on 10/10/23. LPA contacted the administrator, Eunice Kim, who arrived shortly after to allow entry. There is currently no resident residing at the home. The facility is licensed for 6 residents ages 60 and over. There may be (4) ambulatory and (2) non-ambulatory residents. The non-ambulatory is approved for room #1 only. There is a hospice waiver approved for 6 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to assess the facility.
The one story home consists of 4 resident bedrooms, 2 bathrooms, living room, dining room, kitchen, and attached garage. There is a swimming pool in the backyard and is secured by a fence. There are no items obstructing the walkways. There are smoke and carbon monoxide combo detectors located in each room and hallway. The bedrooms are adequately furnished and ready for move-in. The resident medications will be stored in a locked cabinet located in the dining room. The fireplace is not in use and is adequately screened with a lock. There are surveillance cameras around the common areas. Facility has non-perishable items in storage and per administrator, she will purchase perishable items when they receive their first resident. The administrator's certificate expires on 5/15/24 and has current CPR & First Aid certificate. Facility has the updated LIC610E Emergency Disaster Plan with the emergency procedures posted. The facility maintains liability insurance covering the $1,000,000 per occurrence and $3,000,000 in annual aggregate.

There are no deficiencies issued today. A technical violation was given. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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