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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602554
Report Date: 10/07/2025
Date Signed: 10/07/2025 03:17:04 PM

Document Has Been Signed on 10/07/2025 03:17 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KOREAN SENIOR CAREFACILITY NUMBER:
198602554
ADMINISTRATOR/
DIRECTOR:		HAN, SEONG SOOFACILITY TYPE:
740
ADDRESS:20621 SEINE AVENUETELEPHONE:
(714) 504-4257
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 6CENSUS: 6DATE:
10/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:31 PM
MET WITH:Administrator Phyllis LeeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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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

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/07/2025 03:17 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/07/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KOREAN SENIOR CARE
FACILITY NUMBER: 198602554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above no carbon monoxide detector was observed during visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Administrator will install carbon monoxide detector and send LPA picture by POC due date.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) staff did not have a current CPR which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Administrator will send CPR for S1, S2, and S3 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 10/07/2025 03:17 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/07/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KOREAN SENIOR CARE
FACILITY NUMBER: 198602554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above R6 had full bed rails with no order and not on hospice care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Administrator will remove bed rails and send LPA pictures by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/07/2025 03:17 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/07/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KOREAN SENIOR CARE
FACILITY NUMBER: 198602554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one room did not have working smoke detector in bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Administrator changed battieries at time of visit deficiencie cleared.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above resident and staff bathroom did not have hot wate R1 83.2 and R2 81.7 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
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Administrator will adjust water temperature and send LPA pictue by POC due date. Administrator will create one week water log and send to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 03:17 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/07/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KOREAN SENIOR CARE
FACILITY NUMBER: 198602554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above garage was turned into staff bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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Administrator will obtain permits for city or remove items from garage and send pictures or permits to LPA by POC due date.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above five (5) out of six (6) residents did not have an updated physicians report 602 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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Administrator will send documents to LPA by POC due date.
R1 updated 602, R2 updated 602, R3 updated 602 and appraisel needs and service, R4 updated 602 appraisel needs and service plan, R5 incomplete 602, R6 updated 602.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 10/07/2025 03:17 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 10/07/2025 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KOREAN SENIOR CARE
FACILITY NUMBER: 198602554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above facility did conduct any drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
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Administrator will conduct drills with staff and send to LPA by POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KOREAN SENIOR CARE
FACILITY NUMBER: 198602554
VISIT DATE: 10/07/2025
NARRATIVE
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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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
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