Alhambra Villa

Type of visit: Case Management - Annual Continuation

LPA made subsequent unannounced visit to facility to complete annual inspection. LPA met with Ilki Baek, Caregiver and discussed the purpose of the visit. Administrator Julie Coreas arrived shortly and assisted with the visit, The following was observed/inspected. Physical Plant: There are 7 bedrooms that are currently occupied and are equipped with one bed, night stand, chair, sufficient lighting, appropriate closet, drawer space and have the required bedding/linen. Room 4 mattress needs replacement. Bedrooms are large enough to allow for easy passage between beds and other required items of furniture. Sufficient supply of linens available to permit weekly changes are available. Sufficient personal hygiene supplies are available. Laundry machine (washer/dryer) observed and operable. 5 bathrooms have working toilets/wash basin, and shower. The toilet at the end of the facility is leaking and needs repair. Disaster Preparedness: Emergency and Disaster Plan (LIC610E) was posted in the facility but needs updating. The last emergency and disaster drill was conducted on 01/16/2026 Last fire drill was on 1/22/2026. Deficiency noted, technical advisories provided.the state’s words, verbatim · CDSS document, Mar 30, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

This report supersedes previous report, It is being changed to correct type of visit and nothing else has changed. Licensing Program Analyst (LPA) Alberto Lopez conducted an announced annual inspection visit and met with Ilki Baek, Caregiver, and discussed the purpose of the visit. . The facility has an approved fire clearance for 11 non-ambulatory residents, and three (3) bedridden residents. The facility is a single-story home: 9 bedrooms, and 7 bathrooms, dining/ living room, backyard with detached garage used for laundry and storage, located in Alhambra, CA Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, an Infection Control Plan. Bathrooms have hand washing signs, soap and paper towels. Facility Administrator is adhering to infection control requirements. Operational Requirements: Facility has proper fire clearance and shaded area for activities. Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained in Abuse Reporting. Administrator Certificate expires on 09/08/2026. (Continued on 809C) (continued from 809) Resident Rights-Information: resident personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility residents. . (Continued on 809C) Resident Records-Incident Reports: LPA reviewed resident files for C1 through C4. Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights. One resident’s Pre-Admission Appraisal is blank. Details provided to Licensee. Food Service: The facility has sufficient food supplies of 2-day perishable and 7-day supply of non-perishable items. The food is properly stored in the refrigerator, which is clean and well maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept clean and stored properly. Several cans of food are expired and were immediately discarded. Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for R1-R4. The facility uses the Medication Administration Record (MAR) log to document medications given. All medications are not administered as prescribed by the Physician. Some medications do not have orders, and some do not have labels. Details provided to Licensee for corrections. Incidental Medical Services: Per Facility Administrator, there are no residents at this home with incidental medical services or restricted health condition. Emergency Intervention: Not Applicable. LPA will return to complete 2 other domains on another day. Deficiencies noted. Technical violation issued. Exit interview and a copy of this report, appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 23, 2026

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility staff is not keeping Kitchen sanitary Facility does not have enough staff to meet resident's needs Facility is not kept free of pests. Staff are not administering medication to residents as prescribed.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Caregiver Alberta Hacento and explained the purpose of today's visit, and spoke with Licensee Hyo Kim and Administrator Okkyung “Julie” Coreas via phone call. The investigation consisted of the following: On 7/18/25 LPA conducted the inital 10-day visit and obtained copies of staff/resident rosters, toured facility, obtained copy of pest control service agreement, conducted medication review, interviewed 1 residents responsible party, and interviewed 3 staff (S1-S3). During todays subsequent visit 9/19/25, LPA interviewed 4 residents (R1-R4), 1 Staff, and 1 Hospice/Home Health Nurse, inspected kitchen refrigerator and delivered findings for the above allegations. (Continued on LIC9099-C page) Unsubstantiated Allegation: Facility is in disrepair. It is alleged that both the refrigerator in the facility and garage have broken drawers making it difficult to open and take out ingredients, additionally its alleged that the air conditioner (AC) is not accessible to staff to turn on during the hot hours and it’s believed that the air conditioner does not work. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation. During initial visit dated 7/18/25 LPA observed air conditioner to be on and operable. During interviews with staff, it was revealed that the air conditioner is asked to be turned off between 6-8pm as residents complain of the facility being cold in the later evening hours. During initial visit LPA toured kitchen and observed kitchen refrigerator drawer to have a crack in center of the drawer area, opening and closing drawers was difficult as the crack makes the middle of the area bend inwards, creating a dip. During todays subsequent visit the kitchen refrigerator was still in disrepair with the crack in the middle of the bottom shelf making it difficult to open the drawers beneath it. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were emailed av528howardst@gmail.com. Allegation: Facility staff is not keeping Kitchen sanitary. It is alleged that the kitchen is not kept clean and dishes do not have a proper drying rack to dry dishes after washing, causing unsanitized dishes that will have an odor to them. During initial visit dated 7/18/25 LPA observed a dish rack on the kitchen counter that is used to dry dishes after washing. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation and stated that although the dishwasher is not utilized often, there is a removable drying rack on the counter that is used to dry dishes after washing. LPA interviewed 4 residents and each denied the allegation. LPA interviewed R1s responsible party and they denied the allegation stating that they have never observed dirty/unsanitary dishes, and on the times they are present for meals they haven’t observed any issues. LPA interviewed a hospice/home health nurse that services 5 residents at the facility and nurse denied the above allegation stating that during visits they sometimes assist their patients/residents with a glass of water or a snack and dishes have always appeared clean and sanitary. Allegation: Facility does not have enough staff to meet resident's needs. It is alleged that there is only one staff for 11 residents during the hours of 3pm-11pm, making it difficult for that one staff to perform all duties and ensure the safety of the residents. During initial visit there LPA observed 3 staff working in the facility on subsequent visit there were 2 staff working in the facility. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation and stated during morning, day, evening (until 7pm) there is always a minimum of 2 staff, during the night shift there is 1 staff as all residents are usually sleeping during those late hours. Interview with R1’s responsible party stated when they visit there is always at least 2 staff present, and staffing has never been a concern. LPA interviewed 4 residents and each denied the above allegation. LPA interviewed a hospice/home health nurse that services 5 residents at the facility and nurse denied the above allegation stating that during their visits there is always 2-3 staff available to assist the residents. Allegation: Facility is not kept free of pests. It is alleged that there are ants on the kitchen counters and residents bedrooms. During initial visit dated 7/18/25 LPA toured facility, kitchen, resident rooms and bathrooms were inspected and there were no signs of insects. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation. During interview with R1’s responsible party it was stated that they visit 4 times a week and have never observed ants/insects in the facility. LPA interviewed 4 residents and each denied the allegation. LPA interviewed a hospice/home health nurse that services 5 residents at the facility and denied the above allegation stating that they have never observed any insects/ants in the facility during their visits. (Continued on LIC9099-C) Allegation: Staff are not administering medication to residents as prescribed. It is alleged that the facility staff have administered medication to residents outside of time indicated on prescription. LPA conducted a medication review during the initial visit dated 7/18/25, LPA observed medication to be transferred out of their original container and staff were utilizing a weekly pill box, LPA also observed all original medication bottles for R1 to be missing from facility and it was explained that the family prefer to keep it at their home and provide facility with weekly medication pre-packaged boxes, this is against title 22 regulations and citations were issued during the initial visit on a case management visit. During medication review LPA reviewed medication lists, medication and medication administration records and did not find evidence that the facility is not administering the medication as prescribed. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation. LPA interviewed R1s responsible party and they stated that medication has not been an issue and believe staff are administering medication as prescribed. LPA interviewed 4 residents and each denied the allegation. LPA interviewed a hospice/home health nurse that services residents at the facility and they denied the above allegation stating that they have 5 patients they tend to once weekly and during the medication review they do not observe any errors. Based on statements and interviews conducted with staff/residents, facility tour and medication review, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was emailedthe state’s words, verbatim · CDSS document, Sep 19, 2025 · control 28-AS-20250717142205

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 3, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This standard has not been met as evidence by: During initial and subsequent visits LPA inspected kitchen refrigerator and observed the kitchen refrigerator was in disrepair with the crack in the middle of the bottom shelf making it difficult to open the drawers beneath it.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee/Administrator to repair bottom shelf of facility refrigerator and ensure that the drawers beneath the shelf are accessible with no issues. Photos of the repair shall be emailed to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tena Herrera conducted a Case Management Visit-Deficiencies stemming from initial complaint investigation conducted on 7/18/25, complaint control # 28-AS-20250717142205. LPA Herrera met with Licensee Hyo Kim and explained the reason for visit. Case Management-Deficiencies findings: During complaint investigation dated 7/18/25 LPA observed the following - Medication for Resident #1 is missing from facility, all original containers for routine medication were not at facility and Licensee explained that this was because family have taken control of medication and store it with them at their home. LPA observed the LIC622 Centrally Stored Medication form stating that facility is responsible for storing medication. Type A citation will be issued. - Medication for Resident #1 is outside of the original containers and prepacked for a total of 8 consecutive days in a separate medication container packaging dated Sunday through Mondays 8am,9am,2pm and bed. Type A citation will be issued. - Disinfectants and cleaning solutions stored under kitchen sink were unlocked and accessible to residents. The door that separates kitchen from living room was observed to also be unlocked and open during visit from 11am-1:30pm, with staff entering and exiting kitchen, leaving area accessible to residents. Type A citation will be issued. Details for above citations can be found on the LIC809-D page of report. Exit interview held, and a copy of this report and appeal rights were emailed to Licensee and Administraor.the state’s words, verbatim · CDSS document, Jul 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Jul 19, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidence by: Based on record review, the licensee did not comply with the section cited above as, Medication for Resident #1 is outside of the original containers and prepacked for a total of 8 consecutive days in a separate medication container packaging dated Sunday through Mondays 8am,9am,2pm and bed, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Licensee/Administrator shall no longer transfer medications between containers moving forward and email a completed a signed copy of the LIC9098 with this regulation noted on it, this will act as agreement to follow such regulation and as proof that the regulation was reviewed and understood. This shall be emailed to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jul 19, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by: Based on record review, the licensee did not comply with the section cited above as, Medication for Resident #1 is missing from facility, all original containers for routine medication were not at facility and it was expained that the medication is stored at Residents families residence, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Licensee/Administrator to gain possession of all medication for Resident #1, all medication must be maintained at facility and not accessible to persons other than employees responsible for the supervision of the centrally stored medication, and email a completed a signed copy of the LIC9098 with this regulation noted on it, this will act as agreement to follow such regulation and as proof that the regulation was reviewed and understood. This shall be emailed to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 19, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: Based on record review, the licensee did not comply with the section cited above as, Disinfectants and cleaning solutionswere observed to be stored under an unlocked cabinete under the kitchen sink, the door that separates kitchen from living room was observed to also be unlocked and open during visit from 11am-1:30pm, with staff entering and exiting kitchen, leaving area accessible to residents. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Licensee/Administrator to either remove disinfectants/chemicals from under sink and store in a locked/secure area or add a lock to cabinet under sink so chemicals/disinfectants are locked, staff are to ensure these items are no longer left unattened or accessible to residents a completed a signed copy of the LIC9098 with this regulation noted on it shall me emailed to LPA. *during visit Licensee removed all disinfectants/chemicals from unlocked kitchen cabinet and stored in a locked storage closet*

Allegation investigated: Licensee did not provide proper notice of rent increase.

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegation. LPA met with Gabriela Cho, House manager and discussed the purpose of the visit. The investigation consisted of LPA taking a tour of the facility, interviewed three (3) staff S1-S3, three (3) residents R1-R3, two (2) witnesses, W1-W2. Obtaining and reviewing Five (5) resident Admission Agreements and files. LIC9020, and five face sheets for five (5) residents. Reviewing staff and resident rosters . The investigation revealed regarding allegation: Licensee did not provide proper notice of rent increase. It is alleged that facility did not provide proper notice of rent increase to residents at the facility. LPA interviewed three (3) staff and all three (3) stated they were not aware of notice not being proper. LPA interviewed four (4) residents and two (2) of the four (4) residents stated they received notice of rent increase with less than 30 day notice. Staff stated that a total of only five (5) residents received notice of increase. (continued on 9099C) Unsubstantiated (Continued from 9099) LPA reviewed the facilities admission agreements, and they were all signed before the facility became licensed. Due to this fact, the facility did not provide a notice of rent increase because there was no admission agreement at the time of the notice with the rent amount. Licensee has been advised to create an admission agreement for all 12 residents. This will be addressed in a Case Management report. 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. No deficiency is being cited today. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2025 · control 28-AS-20250506133431

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate one allegation. LPA met with Gabriela Cho, House manager and discussed the purpose of the visit. During the investigation, LPA discovered that facility does not have admission agreements with the residents. Facility did not have complete staff files at the facility during visit. LPA advised to keep complete and current staff files at facility at all times, LPA advised licensee to create Admission agreements for all 13 residents and send them to LPA within 10 days.the state’s words, verbatim · CDSS document, May 13, 2025

Allegation investigated: Staff did not meet resident's hygiene needs.

Licensing Program Analyst (LPA) Cynthia Chan conducted the complaint visit regarding the allegation listed above. LPA arrived unannounced and met with Staff, Gabi Cho. The purpose of the visit was explained. During today's visit, LPA interviewed the licensee and Staff #1. Both stated that the individual in question does not reside at this location and was never a resident of the facility. LPA obtained a copy of the resident roster and verified that the name is not on the list. This agency has investigated the complaint alleging, staff did not meet the resident's hygiene needs. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Apr 15, 2025 · control 28-AS-20250414144220

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alberto Lopez made an announced visit to inspect facility to check if corrections have been completed. LPA met with Kim, Hyo Sook, Licensee who assisted with the visit. This is the third Pre-licensing visit. The following was inspected today. · Blinds in the front room need repair or replacement. - Front room has broken blind on window and · Blinds or blackout curtains in rooms and in the living room. - 2 living room windows need black out curtains or blind - All faucets must have cold and hot water within department regulations. - needs corrections. The facility made all the corrections above including maintaining the water temperature which measured between 109.0 - 119.3 during this visit which is within the department regulations. Facility made all corrections and is now ready for license. A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, Licensee has been instructed to communicate with the CAB Analyst who assigned her application.the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA)) Alberto Lopez conducted an announced subsequent pre-licensed visit to verify corrections and met with Hyo Sook Kim, Licensee and Okkyung (Julie) Coreas, Administrator for the purpose of inspecting corrections. The following were inspected and corrected · Side of garage and back of the home needs to be cleared of debris - corrected. · Documents for personnel records need to be available (LIC500) -corrected. - Mattress pads for all beds.- corrected. - Sample Menus for one calendar month. - corrected. - Visiting Policy Posted. - corrected. - Facility needs new shower chair - corrected. - All trash bins must have lids - corrected. - Room #4 needs a lock on the bathroom door and hot water in the faucets. - corrected. - Room 9 needs tub clutter removed. - corrected. - Food for 2-day perishable and 7 days non-perishable and perishable - corrected. - Facility needs to fix fence or replace fence - corrected. - Bedroom 8 needs new dresser. - corrected. - Needs activity calendar - corrected. - Disaster and Mass casualty plan - corrected The following needs correction: · Blinds in the front room need repair or replacement. - Front room has broken blind on window and · Blinds or blackout curtains in rooms and in the living room. - 2 living room windows need black out curtains or blind - All faucets must have cold and hot water within department regulations. - needs corrections. Facility Administrator will advise LPA of corrections to schedule subsequent visit if required. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Mar 17, 2025

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Alberto Lopez and Nicol Wesley conducted an announced pre-licensed visit and met with Hyo Sook Kim, Administrator and Okkyung (Julie) Coreas, for the purpose of conducting a Pre-Licensing Inspection / Component III visit. This Pre-Licensing Inspection is due initial application. The facility has an approved fire clearance for 11 non ambulatory residents, and three (3) bedridden residents. The facility is a single-story home: 9 bedrooms, and 7 bathrooms, dining/ living room, backyard with detached garage used for laundry and storage, located in Alhambra, CA The physical plant was toured inside and out alongside Hyo Sook Kim, Administrator and Okkyung (Julie) Coreas,. Pre-Licensed Inspection Tool was used. The following was observed/inspected. · There are 7 bedrooms that currently occupied and are equipped with one bed, night stand, chair, sufficient lighting, appropriate closet, drawer space and have the required bedding/linen. Remaining 1 bedroom are missing mattress in good repair and all beds are missing mattress pads. · Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture. Sufficient supply of linens available to permit weekly changing are available. · Sufficient personal hygiene supplies available. · Laundry machine (wash/dryer) observed. · 4 bathrooms have working toilets/wash basin, and shower. One tub/shower needs to be cleared of boxes and equipment. One shower has no water. (continued on 809C) (continued from 809) · Smoke Detectors and Carbon monoxide detectors are interconnected approved in the Fire Clearance. · Four (4) Fire extinguishers observed and charged. · Cleaning solutions and sharps need to be locked and stored separately. · Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary. The following was observed/inspected: · Sufficient dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. · Sufficient dining space is available for 12. · Client and Staff files will be stored and locked in a designated file cabinet. · Physical plant is in good repair. · Building and grounds are well kept, debris from side entrance needs to be cleared out · Window screens are in good condition. · There is a shaded area provided in the backyard to accommodate clients, no bodies of water observed. · Hot water temperature measured between 104.1 – 108 and is not within Title 22 regulation. · The residence is equipped with central air and heating, temperature remains at comfortable temp. · Facility has telephone and internet line operable; Facility phone number is 626-656-4222 · Licensee reports no guns or weapons in the home. Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility did not meet the physical plant/inspection requirements as required per California Code of Regulations Title 22 Division 6. The following Corrections need to be made prior to clearing the facility for License. · Blinds in the front room need repair or replacement. · Side of garage and back of the home needs to be cleared of debris · Blinds or blackout curtains in rooms and in the living room. · Documents for personnel records need to be available (LIC500) (Continue on 809C) (continued from 809C) - Mattress pads for all beds. - Sample Menus for one calendar month. - Visiting Policy Posted. - Facility needs new shower chair - All trash bins must have lids - Room #4 needs a lock on the bathroom door and hot water in the faucets. - Room 9 needs tub clutter removed. - Food for 2-day perishable and 7 days non-perishable and perishable - Facility needs to fix fence or replace fence - Bedroom 8 needs new dresser. - Needs activity calendar - Disaster and Mass casualty plan - All faucets must have cold and hot water within department regulations. Licensee will contact LPA when all corrections are in place to schedule subsequent visit. An exit interview was conducted, and a copy of this report has been furnished to Hyo Sook (Monica) Kim, Administrator and Okkyung (Julie) Coreas. Accordingly.the state’s words, verbatim · CDSS document, Jan 27, 2025

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Initial (licensed facility closed 8/30/24 while current application was pending) Capacity: 14 Census (if any clients in care): 10 Method: Telephone call with CAB COMP II Participants: Okkyung Coreas, Administrator; Hyo Kim, Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/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 readinessthe state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Unlicensed care

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the allegation above. LPA met with Staff Evangelina Reyes and discussed the purpose of the visit. LPA called operator Hyo Sook Kim and discussed the conversation she had with the Department on 08/28/2024 where Hyo Sook Kim admitted to operating without a License. The investigation consisted of reviewing staff and resident rosters, and interviews with Applicant Hyo Sook Kim and staff Evangelina Reyes. The investigation revealed: Applicant Hyo Sook Kim has applied for new License at current address Evergreen Senior Care 197608072. Applicant Hyo Sook Kim stated she is running the day to day operations of the facility without an approved License. There are 14 residents that require elements of care and supervision at the facility. There is sufficient evidence to substantiate the allegation. (continued on 809C) Substantiated Based on LPAs observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6. Notice of Violation letter issued. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Evangelina Reyesthe state’s words, verbatim · CDSS document, Aug 30, 2024 · control 28-AS-20240828160538

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.44 · Plan of correction due date: Sep 14, 2024

(a) A facility shall be deemed to be an “unlicensed residential care facility for the elderly” and “maintained and operated to provide residential care” if it is unlicensed and not exempt from licensure, and any one of the following conditions is satisfied: (1) The facility is providing care and supervision, as defined by this chapter or the rules and regulations adopted pursuant to this chapter. (2) The facility is held out as, or represented as, providing care and supervision, as defined by this chapter or the rules and regulations adopted pursuant to this chapter. (3) The facility accepts or retains residents who demonstrate the need for care and supervision, as defined by this chapter or the rules and regulations adopted pursuant to this chapter. (4) The facility represents itself as a licensed residential facility for the elderly. This requirement was not met as evidenced by: Current operator Kim, Hyo Sook stated she has taken over day to day operations of Evergreen Senior Care without an approved License. LPA observed Residents #1-#14 require elements of care and supervision. This poses a potential risk to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: The unlicensed operator shall either cease operation of the unlicensed facility or submit an application to the licensing agency within 15 calendar days. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted, operations cease, or relocate R1-R14 and provide relocation information. Operator has submitted application for Facility License on 07/05/2024