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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204402
Report Date: 08/09/2021
Date Signed: 08/09/2021 05:06:33 PM

Document Has Been Signed on 08/09/2021 05:06 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOME OF ST. COLUMBA, THEFACILITY NUMBER:
198204402
ADMINISTRATOR:EUNMI T KONGFACILITY TYPE:
740
ADDRESS:248 SOUTH MARIPOSA AVENUETELEPHONE:
(213) 389-7760
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 6CENSUS: 3DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ok Hee KimTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control Visit to the above facility. LPA was met by Ok Hee Kim, Administrator and the purpose of today’s visit was explained.

There are currently (3) residents in the facility. The facility consists of : 4 resident bedrooms, 4 bathrooms (1 bathroom is for visitor use), kitchen, family hall with a prayer room and recreation area, dining room, laundry room located inside the kitchen area. Physical plant inside and outside is in good repair.

LPA and Administrator Ok Hee Kim toured the entire facility inside and out. Documents are posted as mandated. Resident bedrooms contain the mandated furniture. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents in administrators office. Medications and files are current and kept in administrator's office. Food supply was adequate for 2-day perishable and 7-day non-perishable. Hot water temperature is 115 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, Exit, walkways and/or passageways, are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap located throughout the facility and additional sanitation supplies are stored in the facility. LPA observed staff and residents wearing masks and keeping 6 ft distance from one another. Client private rooms will be converted to isolation rooms (if needed) and required postings placed throughout the facility. The clients temperature's are checked and logged once a day. PPE's are enough for 30 days.

According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Ok Hee Kim, Administrator and copy of report provided.

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2021
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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