Elim Silvertown

Allegation investigated: Facility staff did not properly report an incident

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced subsequent Complaint visit to the facility. LPA was met by staff in charge Mylene Cho and explained the purpose of the visit. Staff Mylene Cho contacted Administrator Tammie Cha by phone and Administrator joined the visit shortly after. During today’s visit LPA obtained client and staff rosters and toured the physical plant. No immediate health and safety concerns were observed. On the 03/19/26 interviews were conducted with Staff #1-#8 and Residents #1-#10 and the following documents were collected: staff and resident roster, Initial training for nine staff members, SIR for December 2025 and January 2025, Six Caregiver notes for a sampling of SIRs, R1's: Narrative Charting form, Physician’s Report, 02/12/26 doctor's visit and two different Advanced Directive Paperwork. Continued on 9099-C Unsubstantiated On 01/28/26, LPA Sakinah Madyun conducted the initial complaint visit, and obtained copies of staff/resident rosters, five (5) staff files, including and In-Service Training Logs from June 2025 through November 2025 for staff #1-5 (S1-S5), and fifteen (15) residents files, including Physician Reports, Admission Agreements, Appraisal Needs and Services Plans, Identification and Emergency Information Face Sheets, Unusual Incident Reports, Medication Logs and Charting Notes from August 2025 through January 2026 for residents #1-#15 (R1-R15). Applications, Health Screenings, Warning Notices (Supervising Behavior Logs). LPA Madyun indicated that Administrator will email additional documents to LPA. Regarding the allegation: Facility staff did not properly report an incident. It is alleged that facility staff do not properly report incidents, and alleges that R1 was involved in an incident and facility staff did not accurately report the incident. Eight (8) out of eight (8) staff members stated that staff report incidents properly and accurately, and stated that staff receive training on how to report incidents. Nine (9) out ten (10) residents stated that staff report incidents involving residents and incidents are reported accurately. Administrator stated that the facility protocol for reporting incidents involving residents is for the care staff to report what occurred and what staff observed to Medication Technicians (Med Tech) or Licensed Vocational Nurse (LVN). Med Techs and/or the LVNs will document the incident, and the information is shared with Administrator, who then shares the information with any necessary parties. The Administrator states that staff are trained on how and when to report incidents as part of the staff’s initial training. Regarding the incident involving R1, which occurred on 01/02/2026, Administrator states the incident was reported accurately. The report included the time and date that the incident occurred, and all persons involved in the incident and a description of the incident. Per Administrator, R1’s Responsible Party (RP) was contacted by phone within 24 hours after the incident occurred. S5 ,who directly observed the incident involving R1, stated that the incident was reported accurately. Interviews with R1 indicated that R1 was unsure if staff accurately reported R1’s incident to R1s Responsible Party. LPAs reviewed documentation that showed that Med Techs record observed incidents. LPA reviewed facility incident reports for the period, December 2025 through January 2026, and noted that the incident reports contained the essential components; time of incident, date of incident, description of incident and persons present during incident, Continued on 9099-C persons aware of incident. Evidence of initial staff training was found in all the staff files reviewed by LPA, including staff directly involved in reporting R1’s 01/02/2026 incident. Additionally, LPA confirmed the facility reported the 01/02/2026 incident involving R1 to licensing per Title 22 Regulation. LPA reviewed documentation and confirmed R1’s responsible party information. Through interviews and record reviews for this investigation it was revealed that the facility is reporting incidents involving residents properly and accurately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. LPA Mallett conducted an exit interview with Administrator Tammie Cha and a copy of this Licensing report was provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 28-AS-20260121104622

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced Case Management visit to the facility. LPA met with Administrator Tammie Cha and discussed the purpose of the visit. Upon review of the LIC 500 Personnel Summary LPA found that Staff 1 (S1) did not have a criminal background clearance. A deficiency was cited. See 809-D. A Civil Penalty was issued today for the maximum amount of five days in the amount of $500. An exit interview was conducted with Administrator Tammie Cha and copy of this Licensing Report along with a copy of Appeal Rights was provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 20, 2026

Criminal Record Clearance 87355 (e) All individuals subject to a criminal record review... shall prior to working... residing or in a licensed facility: (2) Obtain a California clearance or a criminal record exemption.. the above requirement was not met as evidenced by record review that showed staff 1 did not have criminal record clearance on file.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Administrator will obtain criminal record clearance for Staff 1 prior to Staff 1 returning to work at the facility. Administrator will send a signed statement of understanding of the regulation to LPA via Fax by 03/20/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with med-tech Mylene Cho. Administrator/LVN Tammie Cha arrived later. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. The following were observed/inspected: Infection Control: The facility has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance for 142 non-ambulatory residents, of which 4 may be bedridden. A hospice waiver for 20 residents is approved. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 10/24/2026. Physical Plant/Environment Safety: The facility is a 4-story building with 71 resident rooms, a Memory Care unit located on the 2nd floor, laundry rooms in each floor, medication room, kitchen, dining room/activity rooms located in each floor, library, administration offices, outdoor side yard patio area, and basement parking garage. The interior and exterior was inspected. All common areas and 26 rooms were inspected. Resident rooms have required furniture, bedding, linens, and lighting. However, the majority of resident beds do not have mattress pads. The signal system was tested and is operational. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fire extinguishers. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Two knives and two scissors were observed in the Memory Care Unit unlocked refrigerator freezer. Exit doors are free of any obstruction. The last fire inspection was conducted on 2/13/2026 by CV Fire Protection, Inc. Staffing: A total of 39 staff members provide care and supervision of residents. Personnel Records/Staff Training: Administrator certificate expires 3/2/2026. Staff have criminal background clearance. Nine (9) staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Resident Records/Incident Reports: 10 resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. R1, R5, R6 & R7 have have medical assessments that are more than 12 months old. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. RCFE & Ombudsman complaint posters are posted. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Breakfast meals are cooked on site and lunch and dinner meals are prepared by an outside catering company. Kitchen personnel have current food handling certificates. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. Vitamins were found unlocked in R2's room without a physician order. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 2/19/2026. Residents with Special Health Needs: There are currently 4 residents receiving hospice services, 27 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22, deficiencies were observed and are cited. Exit interview was conducted with Tammie Cha. A copy of report and appeal rights were issued.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Christian Gutierrez conducted a pre-licensing visit. LPA met with Jeong Moon and Tammie Cha. An application was submitted to CCLD for a Change of Ownership for a Residential Care Facility for the Elderly (RCFE) to serve 142 non- ambulatory residents age range 60 and over. The fire clearance has been approved for 138 non-ambulatory and four (4) bedridden only on the first floor. The physical plant was toured with the applicant. Component III was conducted. The facility is a four-story building located in Los Angeles, California. It is licensed for a capacity of one-hundred and forty-two (142) non-ambulatory residents, of which four (4) residents may be bedridden, facility has a hospice waiver approved for eight (8) residents. The facility consists of: (4) floors, a memory care unit on the (2) floor and medication room (1st floor). Main laundry is the basement and there is also a laundry room located on 2nd floor. Medication room, kitchen, administration office, dining room, and library were located at the first floor. LPA conducted a tour with Tammie Cha and observed the following: Each resident bedroom has the required furniture and bedding. There is extra clean linen and towels in basement laundry room. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has several fully charged fire extinguishers throughout the facility. Cleaning supplies and toxic substances were observed inaccessible to residents. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. Bathroom’s grab bars were installed properly, with skid mats in the shower area. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents. Passageways and exits are free of obstruction. SEE 809C Five (5) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) residents files were reviewed and included physicians report, TB clearance, and apparel needs and service. Last fire/earthquake drill was conducted in January of 2025. Infectious control plan was reviewed. Resident’s medications were reviewed, and no discrepancies were found. Medications are centrally stored and locked MAR log is used. No deficiency was observed during today’s visit. Exit interview was conducted with Jeong Moon and a copy of report was provided.the state’s words, verbatim · CDSS document, Feb 11, 2025

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 142 Census (if any clients in care): 127 COMP II Participants: Jeong Mee Moon, Applicant Tammie Cha, Administrator Interview Method: Virtual interview (Microsoft Teams) On January 3, 2025 at 1:30 PM, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant and Administrator. Report sent via email and request to return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Jan 3, 2025