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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610028
Report Date: 05/05/2022
Date Signed: 05/06/2022 09:59:59 AM

Document Has Been Signed on 05/06/2022 09:59 AM - 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:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Yenunje KimTIME COMPLETED:
03:21 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual visit. This annual had an emphasis on infection control practices and procedures. The
LPA spoke with administrator on the phone, and explained the reason for the visit. The administrator stated that they currently do not have residents, they have advertised, but it has been unsuccessful. The administrator was not present for the tour, the facility representative provided the tour.

The LPA and the facility representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.


KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.
BEDROOMS: The residents’ bedrooms were furnished appropriately with clean linens, appropriate
furnishings and sufficient lighting.
RESTROOMS: Restrooms are clean, sanitary and in operating condition. The common bathrooms were observed with appropriate signs and stocked with paper towels.
COMMON SPACES: At the time of the visit, furniture, walls, and flooring were observed to be in good condition. The LPA observed the required postings on the wall in the dinning roomy. The LPA observed sanitizer interspersed throughout the facility. Backyard: The backyard has a patio area with sitting furniture and umbrella for residents and family members to meet.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff and the Licensee Representative
regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station.

No deficiencies cited at this time. Exit interview conducted. Signatures obtained. The report was issued.


SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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