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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603596
Report Date: 10/03/2022
Date Signed: 10/06/2022 03:05:18 PM

Document Has Been Signed on 10/06/2022 03:05 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LOVE HOME CARE FOR ELDERLYFACILITY NUMBER:
198603596
ADMINISTRATOR:KIM, JUNG HYUNFACILITY TYPE:
740
ADDRESS:22935 HAPPY HOLLOW RDTELEPHONE:
(909) 217-2011
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 0DATE:
10/03/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator/ Kim, Jung HyunTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) YaTing Yang and Joe Katrdzhyan conducted an announced pre-licensing visit. LPAs met with Administrator/Kim, Jung Hyun and staff Kim, Jeunghon for the purpose of conducting a pre-licensing inspection. Licensees /Kim, Jung Hyun, Kim, Jeunghoan have submitted a license application to operate a Residential Care Facility for the Elderly for a capacity of six (6) residents, ages 60 and over. The facility has a fire clearance approved for four (4) ambulatory residents and two (2) non-ambulatory residents only. Two (2) non-ambulatory in room with exterior door (Bedroom 1). Licensee has hospice waiver approved for six (6). Fire clearance was granted on 8/15/22. The new application is being processed as an initial license. There are currently zero (0) residents living at the facility. Licensees /Kim, Jung Hyun, Kim, Jeunghoan have submitted a Dementia Care Program with the application.


LPAs 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. The facility consists of a main floor. A tour of the main floor includes a living room, kitchen, dining area, four (4) resident rooms, two (2) shared bathrooms, one of which is located in bedroom 1, office area, medication area, laundry area, multiple storage cabinets, and indoor/outdoor activity areas, and attached garage. The facility has a temperature screening station at the entrance. LPAs were screened for temperature upon entry.

LPAs observed two exit gates enclosed by doors with self-closing mechanism. LPAs also observed a fully equipped living room with an enclosed fireplace and exit door connected to the backyard. The dining room has sufficient dining capacity. Resident bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Resident bedrooms were equipped with a bed, chair, night stand, adequate lighting and ample closet/storage space for each resident. Bedroom #1 for two non-ambulatory residents has an exit door with an auditory chime. The bathrooms are clean and operational with non-skid mats and paper supplies. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and appeared functional. The supply of dishes/cups was adequate. During today's visit, LPAs observed the food supply of seven (7) days of non-perishables. The administrator ensures that she will purchase two (2) days of perishable foods upon licensure. Medications will be centrally stored and locked in the cabinets located in the office area. Resident and staff records will be centrally stored and locked in the cabinet located in the hallway, making it inaccessible to the residents. First Aid Kit was observed fully equipped with the current First Aid manual. Continue 809-C.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: YaTing Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LOVE HOME CARE FOR ELDERLY
FACILITY NUMBER: 198603596
VISIT DATE: 10/03/2022
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LPAs observed one the fire extinguisher fully charged and in compliance. The facility is equipped with a centralized AC and heating system. Per Administrator, the facility will NOT be handling resident's P&I and other cash resources. All sharp objects and knives are stored in the kitchen cabinet making it inaccessible to residents. All toxins, cleaning solutions and supplies are locked underneath the kitchen sink, making it inaccessible to residents. No firearms will be kept at the facility. The facility smoke detectors and carbon monoxide detectors were hardwired and tested operational throughout the facility. There is a functioning telephone on the premises. The hot water temperature was measured throughout the facility between the range of 105 to 120 degree Fahrenheit and in compliance. A swimming pool in the backyard is fenced and in compliance with state and local building codes. Per the Administrator/Kim, Jung Hyun, the residents will NOT be using the swimming pool at all times. The attached garage is being used as a storage and will be kept accessible to the residents. The washer and drying machine are located in the garage.

No concerns were observed during today's visit.


Component III was conducted during this visit.

LPAs used the inspection tool and the pre-licensing checklist for a Residential Care Facility for the Elderly during this visit.

An exit interview was conducted and a copy of the report was provided to the Administrator.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: YaTing Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC809 (FAS) - (06/04)
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