Suncoast Senior Living at Long Beach

Type of visit: Required - 1 Year

On September 13, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced annual required visit. LPA met with administrator Ki Hwan "Tony" Kim and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for (6) hospice resident. There are currently five (6) residents in care. Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, six (6) bathrooms, a living area, a dining area, a kitchen, and outside patio area. Physical Plant: LPA Lee and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. The water temperature ranged from measured between 105 and 120 degrees F. Page 1 of 3 Bedrooms LPA inspected all six (6) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting. Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in a cabinet under the sink. The water measure between 105-120 degrees F. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations. Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets. LPA observed incontinence care products stored in the supply area. LPA observed an extra supply of hygiene products secured in the garage and in the supply area of the home. Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutleries, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in a mental locked in the kitchen and are inaccessible to residents. LPA observed a 2-day supply of perishable foods and a 7-day supply of nonperishable foods. All food was properly stored and labeled. Additional food and water located in the attached garage where there is an additional refrigerator and freezer. page 2 of 3 Safety During the visit, LPA observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. All fire extinguishers were fully charged all bought within 1 year. The last Fire/Disaster Drills were conducted on 8/5/25 Files and postings: LPA reviewed 6 resident files and found 6 out of 6 contained all the necessary documentation. LPA reviewed 3 staff files and found 3 out of 3 contained the required documentation, certification, and training. LPA observed all required posting throughout the facility. General Liability current: expires on 7/31/26 Medication LPA observed all centrally stored medications in their original packaging and are secured in cabinet in kitchen. There were no deficiencies during today's visit. An exit interview was conducted with licensee and a copy of this report was provided to Licensee Ki Hwan "Tony" Kim. Page 3 of 3the state’s words, verbatim · CDSS document, Sep 13, 2025

Allegation investigated: Staff interfered with resident's visit with the Long Term Care Ombudsman

** This report serves to amend the 9099D.It does not supersede the complaint investigation findings reflected on report created on 1/24/25 ** On January 24, 2025, Licensing Program Analyst (LPA) Deborah Lee arrived at the facility listed above for the purpose of continuing investigation started on 10/3/24 and to deliver findings for the above identified complaint allegation. LPA Lee met with Licensee/Administrator Tony Kim and explained the reason for today’s visit. There was one staff (S1) at facility at time of visit. The complaint alleges that Licensee/Administrator Tony Kim insisted on supervising the Long Term Care Ombudsman (LTCO) while she spoke with the residents. The investigation consisted of the following: LPA Lee conducted tour of facility both inside and out, LPA reviewed and obtained copies of the following: client roster, staff roster, Appraisal/Needs and Services plans for (R1), Physicians reports for (R1), interviews were conducted with the following: Licensee/Administrator, LTCO (via telephone), Staff #1 (S1) and Residents (R1-R5) Page 1 of 2 Substantiated Allegation: Staff interfered with resident's visit with the Long Term Care Ombudsman Regarding the allegation: Licensee/Administrator Tony Kim interfered with resident's visit with the LTCO (W1). It is alleged that W1 arrived at facility to conduct an annual visit on 8/30/24 when the Licensee/administrator (Tony Kim) insisted on supervising W1 while she spoke with resident (R1); therefore, interfering with her duties . On November 5, 2024, Licensing Program Manager (LPM) Eva Alvarez and Licensing Program Analyst (LPA) Deborah Lee conducted a telephone interview with W1 who confirmed the allegation stating that she was interfered with while conducting her duty of meeting privately with the residents. When explaining that she had authority to meet privately with residents without interference, Mr. Kim continued to argue about her being in the resident's room without him. W1 further stated that she decided to terminate the visit because Mr. Kim wanted the visit to be on “his terms” by being present during her meeting with residents which goes against their rights to meet with the LTCO privately. On November 5, 2024, LPA Lee interviewed Licensee/Administrator Tony Kim via telephone who informed her that during W1’s visit to the facility, while in R1’s room, he needed to be present with W1 for safety reasons but W1 stated that she needed to speak privately with R1. According to Mr. Kim, W1 began yelling, “I can go anywhere I want, and you can’t stop me!” Mr. Kim further stated that he told her to “get out of the room right now and get your supervisor on the phone.” Lastly, Mr. Kim stated that shortly after W1 and her supervisor spoke on the phone privately outside of facility, W1 said she was ending her visit and left the facility. On January 24, 2025, LPA interview with staff 1 (S1) reveal that residents' family and other visitors have met privately with residents. Interviews with R1-R5 reveal that (1 ) out of ( 5) residents is familiar with a Long Term Care Ombudsman (LTCO) and after LPA Lee explained what a LTCO does, ( 4 ) out of ( 5) residents said they would be okay with meeting and speaking with an LTCO privately. Based on interviews conducted, the preponderance of evidence standard has been met therefore the above allegation is found to be SUBSTANCIATED. Citation issued during today’s visit please see LIC 9099Dthe state’s words, verbatim · CDSS document, Jan 24, 2025 · control 11-AS-20240924120338

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(11) · Plan of correction due date: Mar 7, 2025

Personal Rights. (a) Each resident shall have personal rights which include, but are not limited to, the following: (11) To have his/her visitors, including ombudspersons and advocacy representatives permitted to visit privately...provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by Based on interviews, the licensee did not comply with the section cited above as he prevented the Long Term Care Ombudsmen from speaking privately with Resident in care which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Licensee to come up with a plan to allow privacy for subsequent visits from the Long Term Care Ombudsman. Plan to be submitted to LPA via email by due date (03/07/2025) Deborah.Lee@dss.ca.gov.

Type of visit: Case Management - Deficiencies

On October 3, 2024 Licensing Program Manager (LPM) Eva Alvarez and Licensing Program Analyst (LPA) Deborah Lee conducted a complaint visit at this facility. During this visit deficiencies were observed. LPA and LPM met with Licensee Tim Kim during this visit. During LPA's visit LPA Lee was unable to verify a criminal record clearance and association for Staff #2 (S#2). LPA found S#2 has no record of having obtained a criminal record clearance and is not currently associated to this facility. LPA found Staff #1(S#1) obtained a criminal clearance; however, is not associated to this facility. Licensee Kim stated, attempts have made to associate S#1 through the CCL Guardian portal. Licensee Kim stated he has been unable to associate S#1 through the Guardian portal and has communicated via e-mail with the Care Provider Management Branch. The Licensee has provided a completed LIC 9182 criminal background clearance transfer request to LPM Alvarez. The LIC 9182 will be processed by the Regional Office on 10/4/2024 to associate S#1. Title 22, Division Chapter 1, Article 03. is being cited, please see attached LIC809D. An exit was conducted, and plans of correction was developed with the administrator. A copy of this report and the appeals rights was provided.the state’s words, verbatim · CDSS document, Oct 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 4, 2024

All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility.ottain a California clearance. This requirement was not met as evidenced by: LPA was unable to to verify S2 criminal clearance or association to facility. Which poses an immediate health & safety risk.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: LIcensee will ensure that S2 obtains a criminal records clearance and association to facility prior to working in the facility. Licensee will ensure S2 shall not work in the facility until a clearance is obtain. Violation of Section 87355(e) will result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation for a maximum of 5 days by the Department. Civil penalties have been assesed for th amount of $500.00.

Type of visit: Required - 1 Year

On September 6, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced annual required visit. LPA met with administrator Ki Hwan Kim and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for (1) hospice resident. There are currently five (6) residents in care. Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, six (6) bathrooms, a living area, a dining area, a kitchen, and outside patio area. Physical Plant: LPA toured the physical plant. All rooms were inspected. LPA observed the facility to be furnished at time of visit with ample seating for the Residents in care. There is adequate lighting in the facility and the temperature was comfortable 75 degrees F. Hallways and passageways were free of obstruction. A working landline telephone remains available. Bedrooms LPA inspected all six (6) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, nightstands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting. page 1 of 3 Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in a cabinet under the sink. The water temperatures measured 108.9, 107.9,110, and 106 degrees Fahrenheit respectively. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations. Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets. LPA observed incontinence care products stored in the supply area. LPA observed an extra supply of hygiene products secured in the garage and in the supply area of the home. Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutleries, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in a mental locked in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All food was properly stored and labeled. Additional food and water located in the attached garage where there is an additional refrigerator and freezer. Page 2 of 3 Infection Control Practices: During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted LPA observed all required postings: Personal Rights, Ombudsman information poster, see something say something poster, facility sketch, California employee wage information (Federal and State), menus and activities. LPA observed that there are fully stocked First Aid Kit supplies in the home. Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet in the kitchen area. Files LPA reviewed six (6) resident files and found they contained all the necessary documentation. LPA reviewed four (4) staff files and found they contained the required documentation. LPA reviewed copies of Client Roster, Staff Roster, Emergency and Disaster Plan (LIC610E). Liability Insurance expires on 08/1/2025. The facility has 6 fire extinguishers, and 11 operable smoke detectors/carbon monoxide combination. The detectors are interconnected and can be heard throughout the facility. LPA issued Technical Advisory notes during this visit. An exit interview was conducted with licensee and a copy of this report was provided Page 3 of 3the state’s words, verbatim · CDSS document, Sep 6, 2024

Allegation investigated: Staff are not meeting a fire safety requirement

On 11/03/23 Licensing Program Analyst (LPA) Mario Leon delivered an amended report. This is an amendment of a report provided on 10/17/23. The purpose of this amendment is to provide additional information regarding the investigation conducted for this complaint. Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit to above facility. LPA arrived at facility and was met by Sofia Ociones, Assistant Administrator, and explained the purpose of the visit is to investigate on the allegation listed above and was allowed entry to the facility. The investigation consisted of the following: On 10/16/2023 LPA conducted record reviews of California Code of Regulation, Title 19 - Public Safety Division 1 - State Fire Marshal Chapter 3 - Fire Extinguishers Article 6 - Inspection, Maintenance and Required Service Intervals - § 575.1 - Maintenance and Required Service Intervals, which indicates that fire extinguishers shall be subjected to maintenance annually as described in this chapter. On 10/17/2023 LPA toured the inside and outside grounds of the facility and requested copies of facility documents. LPA conducted interviews with four (4) facility staff (S1-S4). Report continues, see LIC9099C Substantiated The investigation revealed the following: Allegation: Staff are not meeting a fire safety requirement. It has been alleged that the fire extinguisher(s) present at the facility do not have service records, purchase records, or do not have tags blocked in showing proper yearly inspection by licensed State Fire Marshall officials. During today's tour of the facility, LPA and Assistant Administrator, Sofia Ociones, inspected two fire extinguishers by the bedroom hallway. LPA and Assistant Administrator did not observe both fire extinguishers showing any service records, purchase records or tags showing yearly fire inspection by a State Fire Marshall official. LPA requested the quarterly fire drill, proof of purchase of fire extinguisher or service records from Assistant Administrator. Assistant Administrator was not able to provide records as requested. Based on LPA’s observation and interviews 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 six (6) is being cited on the attached LIC 9099D. An exit interview was held with Assistant Administrator, Sofia Ociones, and a copy of this report and appeal rights have been provided.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 11-AS-20231010121617

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Oct 18, 2023

Fire Safety. All facilities shall be maintained in conformity with the regulation adopted by the State Fire Marshal for the protection of life and property against fire and panic. This regulation is not met as evidenced by: Based on record reviews, observation and interviews the licensee failed to ensure that fire extinguishers are subjected to annual maintenance per Title 19, Divison 1 -State Fire Marshal, Chapter 3 - Fire Extinguisher which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: LPA and Assistant Administrator have agreed that Assistant Administrator will purchase two (2) new fire extinguishers, provide LPA receipt of purchase and will keep yearly records of services on file moving forward. LPA email address: Mario.Leon@dss.ca.gov