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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603596
Report Date: 07/06/2023
Date Signed: 07/06/2023 11:52:48 AM

Document Has Been Signed on 07/06/2023 11:52 AM - 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:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jung "Eunice" Kim, LicenseeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced case management visit in regards to the incident that occurred at Happy Home Care for Elderly on 6/24/23. This facility is partly owned by Jung Hyun Kim. The facility is licensed for 6 residents, ages 60 and over, of which (2) may be non-ambulatory approved in room #1 only. There is also an approved hospice waiver for 6 residents.

Licensee, Jung "Eunice" Kim arrived at 10:45 a.m. and allowed entry to the home. Per licensee, she has not accepted any residents since obtaining the facility license. LPA toured the facility inside and out. LPA did not observe any concerns and verified there are no residents requiring care and supervision residing at the home. There were no files or medications reviewed during the visit today.

There are no deficiencies issued today. An exit interview was held and a copy of this report was given to the Mrs. Kim.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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