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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603169
Report Date: 01/12/2022
Date Signed: 01/12/2022 01:22:19 PM

Document Has Been Signed on 01/12/2022 01:22 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:HOPE HOME CARE FOR ELDERLYFACILITY NUMBER:
198603169
ADMINISTRATOR:KIM, JUNG HYUNFACILITY TYPE:
740
ADDRESS:23916 HIGHLAND VALLEY RDTELEPHONE:
(909) 217-2011
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 1DATE:
01/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:S-1/Facility AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra completed this Case Management-Deficiencies report during (2) complaint investigations. File review revealed that R-1 independently moved into this facility and resided at this facility from 12/28/2021 through 01/03/2022. During this visit, LPA observed R-1 did not have a Physician's Report on file. Per Administrator, R-1 was in the process of obtaining a Physical exam.

Deficiency cited under California Code of Regulations Title 22. Refer to LIC 809D.

Exit interview conducted, a copy of this report and Appeals Rights provided to S-1/Facility Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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 2
Document Has Been Signed on 01/12/2022 01:22 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 01/12/2022 at 12:31 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: HOPE HOME CARE FOR ELDERLY
FACILITY NUMBER: 198603169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2022
Section Cited
CCR
87458(a)(1)

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87458 Medical Assessment: (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.

This standard is not met as evidency by:
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Facility Administrator to provide a written statement as to how the facility will be in complaince with this regulation to LPA Irra by POC due date.
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File review revealed that R-1 independently moved into this facility and resided at this facility from 12/28/2021 through 01/03/2022. During this visit, LPA observed R-1 did not have a Physician's Report on file. Per Administrator, R-1 was in the process of obtaining a Physical exam.
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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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022


LIC809 (FAS) - (06/04)
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