Korean Senior Care

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPA’s) Christian Gutierrez, and Elena Mallett conducted the required annual inspection. LPA’s arrived unannounced and met with Phyllis Lee - Assistant Administrator and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60 and over (dementia approved), with a Hospice waiver for 2. There are no Residents with Hospice services at the moment. The facility is a single-story home located in Lakewood, Ca. A tour of the facility includes: 4 resident bedrooms, 1 bathroom, living room, kitchen, laundry area, front yard, and backyard. There is a separate area for staff that includes bedroom, living room, 1 staff bathroom, washer/dryer, and a staff office area with a surplus of canned foods/refrigerated food and washer and dryer. All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, and lighting. LPA’s observed full bed rails for one (1) resident not on hospice care. Smoke detector in bedroom #4 was not working at time of visit. No carbon monoxide detectors were observed in facility. The facility has three (3) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible locked in closet and under kitchen sink. 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 The resident bathrooms have the required grab bars and non-skid mats. The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F. The common areas, including the living room and dining area, are clean and have the required furniture. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents in front yard. Passageways and exits are free of obstruction. LPA’s observed garage to be converted into bedroom for staff deficiency cited. SEE LIC 809C Three staff files reviewed included criminal clearance record, health screening with TB, three (3) out of three (3) staff did not have valid CPR/First Aid. Five (5) out of six (6) resident files reviewed and did not have updated physicians’ reports, R3 and R4 were missing appraisal needs and service plans. No fire/earthquake drill was available. Infectious control plan was reviewed. Six (6) resident medications were reviewed. Medications are centrally stored and locked MAR log is used. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview was held and a copy of the report along with appeal rights will be emailed due to printer problems.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Phyllis Lee - Assistant Administrator and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60 and over (dementia approved), with a Hospice waiver for 2. There are no Residents with Hospice services at the moment. The facility is a single-story home located in Lakewood, Ca. A tour of the facility includes: 4 resident bedrooms, 1 bathroom, living room, kitchen, laundry area, front yard, and backyard. There is a separate area for staff that includes bedroom, living room, there is also 1 staff bedroom and Staff office area with surplus of canned foods/refrigerated food. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: Staff are cleaning and disinfecting throughout the day and have an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. (continued on LIC809-C) Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Seong Soo Han maintains a valid Administrator Certificate that expires on 3/2/2026. Resident Records-Incident Reports: Resident files are kept in a secure location (within staff office area) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files, there will be a citation as 1 out of 4 files reviewed was missing an updated needs and service plan, last updated plan was when resident was admitted in 2017, details will be found in the LIC809-D Residents Rights-Information: Residents are provided with telephone and internet at the facility. Planned Activities: Facility provides a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 6 residents’ medications and there were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The facility did not have record of the last Fire/Earthquake/Emergency Disaster Drill, citation will be issued and details will be found on LIC809-D. Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. Residents with half-bed rails had a prescription for them within their file. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit will be detailed in the LIC809-D. Exit interview held and a copy of the report and appeal rights were provided to Phyllis Lee.the state’s words, verbatim · CDSS document, Sep 9, 2024

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