Korean Senior Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met Phyllis Lee - Assistant Administrator and explained the reason for the visit. The facility is licensed to serve six non-ambulatory residents ages 60 and over and may retain up to two hospice residents. The facility is operating within the scope of its license. A tour of the single-story facility included: 4 resident bedrooms, 1 bathroom, living room, kitchen, laundry area, front yard, and backyard. LPA and Phyllis toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the bathroom and measured at 118.9 degrees F which is within the required 105 - 120 degrees F. The bathroom is clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a living room closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the hallway and it is properly operating. A fire extinguisher was observed in the kitchen and hallway which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Knives are kept locked under the kitchen sink. Cleaning chemicals are kept locked in the living room closet. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the front yard. There are no bodies of water. Passageways and exits are free of obstruction. Residents medication are centrally stored in a locked hallway cabinet. Residents and staff files are centrally stored in the medication cabinet. LPA reviewed medication for 4 of the residents and observed that medications are given as prescribed. The other 2 residents do not have medication prescribed to them. LPA reviewed files for 6 residents and 5 staff and observed no deficiencies. (Continued to LIC 809-C) LPA observed administrator certificate for Seong Soo Han - 6042329740 with an expiration date of 03/02/2024. LPA interviewed 2 residents and 1 staff. Facility has a valid liability insurance. Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed. Exit interview held and a copy of the report were provided.the state’s words, verbatim · CDSS document, Oct 27, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Wong conducted an unannounced case management visit to the facility. The purpose of today's visit was to serve the Order of Licensee/Administrator of Immediate Exclusion from facility for Staff#1 (S1). An investigation by California Department of Social Services was concluded and it was determined that S1 violated California Code of Regulation Title 22 for personal rights. On today's visit, LPA met with Administrator Phyllis Lee and explained the reason of the visit. Administrator provided with copies of the Order of Licensee of Immediate Exclusion and Order to Individual for Immediate Exclusion and Government Code 11522. Exit Interview held. A copy of the report was provided to Administrator Phyllis Lee.the state’s words, verbatim · CDSS document, Aug 22, 2023

Allegation investigated: Staff left the residents unattended while in care

*****This report serves as an amendment and supersedes the original complaint investigation report dated 4/4/2023. The reason for amendment is to add additional information on LIC9099 and LIC9099C and make corrections on LIC9099D. Investigation finding remain the same. ****** Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Administrator Seong Soo Han who allowed entry into the facility and assisted with the visit. The investigation consisted of the following: LPA interviewed administrator and three staff (S1-S3) and six residents (R1-R6) and obtained copy of R1's documents including face sheet, pre-appraisal, and physician report. (See LIC9099C for continuation) Substantiated The investigation revealed of the following: Allegation "Staff left the residents unattended while in care." LPA interviewed residents and they all feel safe living in the facility and the staff treated them good. LPA interviewed staff and admitted the staff did leave the residents unattended while in care. Administrator reported the facility usually have three staff work in the facility after dinner but on 03/28/23, the administrator and wife went out for dinner. S1 was the only staff on duty at that time yet she left the facility for approximately 15 minutes leaving 6 residents unattended including at least one that was bedridden. One of the residents began to bang on the window asking for help resulting in the police being called. Firefighters were called to the location and made entry through a window. Although law enforcement did not observe any injuries on the residents in placement, the caregiver was arrested when she returned to the facility for neglect/absence of supervision and will be appearing in court at a later date. Based on LPA’s interviews, and review of documentation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to the facility staff left the residents for absence of supervision. Refer to LIC 421IM*** An exit interview conducted, a copy of the report and appeal right was provided to the administrator Seong Soo Han.the state’s words, verbatim · CDSS document, Apr 4, 2023 · control 28-AS-20230329131939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 5, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The requirement was not met as evidenced : By LPA's interview, the staff let residents unattended which posed an immediate risk to residents in carethe state’s words, verbatim · CDSS document, Apr 4, 2023

Plan of correction: The administrator will provide to training staff about the regualtion and send the training log to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met Phyllis Lee - Assistant Administrator and explained the reason for the visit. The facility is licensed to serve six non-ambulatory residents ages 60 and over and may retain up to two hospice residents. The facility is operating within the scope of its license. The facility is located in a residential area. A tour of the single-story facility included: 4 resident bedrooms, 1 bathroom, living room, kitchen, front yard, and backyard. LPA and Phyllis toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the bathroom and measured at 115.4 degrees F which is within the required 105 - 120 degrees F. The bathroom is clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a living room closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the hallway and it is properly operating. A fire extinguisher was observed in the kitchen and hallway which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Knives are kept locked under the kitchen sink. Cleaning chemicals are kept locked in the living room closet. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard and front yard. There are no bodies of water. Passageways and exits are free of obstruction. (CONTINUED TO LIC 809C) Residents medication are centrally stored in a locked hallway cabinet. Residents and staff files are centrally stored in the medication cabinet. LPA reviewed medication for 3 of the residents and observed that medications are given as prescribed. The other 2 residents do not have medication prescribed to them. LPA reviewed files for 5 residents and 4 staff and observed no deficiencies. LPA observed administrator certificate for Seong Soo Han - 6042329740 with an expiration date of 03/02/2024. Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed. The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by 01/03/2023. Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed. Exit interview held and a copy of the report were provided.the state’s words, verbatim · CDSS document, Nov 4, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the infection control domain. LPA arrived unannounced and met with Staff, Phyllis Lee. The purpose of the visit was explained. The facility is licensed for 6 non-ambulatory residents, age 60 and over. There is an approved hospice waiver for 2 residents. LPA toured the facility with the staff and observed the following: * Upon entry, there was a station set up to take visitors' temperature and for visitors to take the screening questionnaire. * There is one entry point for staff and visitors. * There was a sufficient supply of 2 -day perishable and a week of non-perishable foods in storage. * Residents' rooms have the required furnishings. * Knives and sharps are stored and locked in the kitchen area under the sink. * Medications are locked and centrally stored. Medications were reviewed for 3 residents and a 30-day supply was maintained at the facility. * Visitation area is set up outdoor by the main entrance. * Staff were wearing face coverings. * Extra PPE supplies are stored in the living room closet. The following technical advisories were provided on the LIC9102 form: * Postings to promote hand washing, cough/sneezing etiquette, and physical distancing. * N95 Fit testing No deficiencies were observed during the visit today. An exit interview was conducted with Staff and a copy of this report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 21, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.