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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610028
Report Date: 06/09/2021
Date Signed: 06/09/2021 04:03:23 PM

Document Has Been Signed on 06/09/2021 04:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HOLLYWOOD CARE HOMEFACILITY NUMBER:
197610028
ADMINISTRATOR:LEE, KYONG SUKFACILITY TYPE:
740
ADDRESS:13307 STAGG STREETTELEPHONE:
(909) 618-7575
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 0DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Clara LeeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA’) Sandra Urena and Salia Walker conducted an unannounced Required -1 Year inspection. LPAs arrived at the facility at 2:15pm. LPAs met with Administrator Clara Lee, who stated that they currently have no residents and do not anticipate having residents until the end of 2021.


LPAs conducted a facility tour at 2:20pm to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common area, four bedrooms, and two restrooms were conducted. At 2:40pm LPAs conducted the Outdoor area tour- passageways are free of obstruction, a sitting area is designated for outdoor residents and family members to gather. LPAs did not observe any residents in care during facility visit. PPE supplies were observed. LPAs observed the fire extinguisher fully charged. The smoke alarms and carbon monoxide detector were tested and were operable.

No citations issued during today's visit.

Exit interview conducted, today's report was reviewed and emailed to the Administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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