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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603169
Report Date: 11/04/2025
Date Signed: 11/04/2025 04:20:46 PM

Document Has Been Signed on 11/04/2025 04:20 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:HOPE HOME CARE FOR ELDERLYFACILITY NUMBER:
198603169
ADMINISTRATOR/
DIRECTOR:		KIM, JUNG HYUNFACILITY TYPE:
740
ADDRESS:23916 HIGHLAND VALLEY RDTELEPHONE:
(909) 217-2011
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
11/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Eunice Kim - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Hyo Seon Kwak, Caregiver and explained the purpose of today's visit. Shortly after, Eunice Kim, Administrator and John Kim, RN arrived and assisted LPA. The facility is approved for age range 60 and over, approved for capacity of (4) ambulatory and (2) non ambulatory. Facility has approved hospice waiver for (6) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices are maintained and staff are adhering to infection control requirements. The use of Infection Control procedures are reviewed/updated. Staff ensure that residents are regularly observed for physical, mental, emotional and social functioning changes. Staff ensure that appropriate assistance is provided and such changes are documented and brought to the attention of the residents' physician.
Operational Requirements: The Infection Control Plan has been added to the Plan. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid, expires on 07/07/2026.
Physical Plant & Environment Safety: This facility is a single story home consists of kitchen, dining room, living room, (4) resident bedrooms, (1) office, (3) bathrooms, attached garage, and a shaded patio with seating. Currently, there are (6) residents living in the home. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. LPA observed a fire extinguisher near the dining area purchased on 09/08/2025. Knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. LPA observed a shed in the backyard being used as a resting area/bedroom for staff. There are surveillance cameras in the common areas.*****Refer to LIC 809C for the continuation of this report.*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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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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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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: HOPE HOME CARE FOR ELDERLY
FACILITY NUMBER: 198603169
VISIT DATE: 11/04/2025
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Staffing: A total of five (5) staff members including the night staff and Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Current Administrator's certificate is pending, expires on 05/15/2026.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (5) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current. Dementia care is part of training for direct care staff.
Resident Rights-Information: Resident rights are posted. Facility provides internet service and phone to the residents.
Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. There is one (1) resident with special diet residing at this facility.
Incidental Medical Services: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. Administrator did not indicate the time in which residents' medications were administered in a given day.
Resident Records-Incident Reports: LPA reviewed (5) resident files. Residents files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan which is posted. Facility conducts emergency drill (earthquake & fire) at least quarterly. Last fire and earthquake drills were conducted on 10/01/2025.
Residents with SHN: Facility accepts and retains residents with dementia. Facility has sufficient space to permit residents with dementia to wander freely and safely. Administrator ensures that there is at least one night staff person awake and on duty for night supervision of residents with dementia. LPA observed (3) residents with bed rails, however, only (2) residents have physician's authorization. One of the residents, (R5) is not receiving hospice care has full bed rail that is prohibited. Additionally, R5 does not have a physician's order on file.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy this report was provided to Administrator, Eunice Kim.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2025 04:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 11/04/2025 at 02:23 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: 11/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that the Administrator did not indicate the time in which residents' medications were administered in a given day which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator agreed to consult with the residents physicians about the medication schedule and update the Medication Administration Record (MAR) to reflect the time. Administrator will send a copy of the updated MAR to LPA/CCL by POC due date.
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, interview, record review, the licensee did not comply with the section cited above in that one of the residents, (R5) is not receiving hospice care has full bed rail that is prohibited which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator requested R5's physician to send a written order for the 1/2 bedrail and provided it to LPA during the visit. ****DEFICIENCY CLEARED DURING THE VISIT.***
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
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