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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603596
Report Date: 10/08/2024
Date Signed: 10/08/2024 04:24:06 PM

Document Has Been Signed on 10/08/2024 04:24 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/
DIRECTOR:		KIM, JUNG HYUNFACILITY TYPE:
740
ADDRESS:22935 HAPPY HOLLOW RDTELEPHONE:
(909) 217-2011
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 2DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Eunice Kim, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 10/8/24. LPA arrived unannounced and explained the reason of the visit to licensee/administrator, Eunice Kim. The facility is licensed for 6 residents ages 60 and over. There may be (4) ambulatory and (2) non-ambulatory residents. The non-ambulatory is approved for room #1 only. There is a hospice waiver approved for 6 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility.
The single story home consists of 4 resident bedrooms, 2 bathrooms, living room, dining room, kitchen, and attached garage. There is a swimming pool in the backyard and is secured by a fence. The fireplace is adequately screened with a lock. There are no items obstructing the walkways. There are smoke and carbon monoxide combo detectors located in each room and hallway. The bedrooms have the required furniture and storage space. There is sufficient lighting throughout the facility. Facility has sufficient food supplies of perishable and non-perishable. The hot water temperature was measured within the required range of 105-120 degrees F. There are surveillance cameras located in the common areas.
Medications are centrally stored and locked in a cabinet located in the dining room. LPA reviewed medications for 2 residents and no discrepancies were found. Both residents' files were reviewed and Resident #2's physician's report was not current. LPA reviewed 3 personnel files. The administrator's certificate expires on 5/15/24 but was verified that the renewal documents were submitted. Staff have current CPR & First Aid certificates, health assessment and TB results, and on-going training. Facility has the updated LIC610E Emergency Disaster Plan with the emergency procedures posted. Licensee is conducting emergency disaster drills with staff. The facility has appropriate liability insurance covering the $1,000,000 per occurrence and $3,000,000 in annual aggregate.

LPA issued a deficiency on the LIC809D form. A technical violation was given. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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Document Has Been Signed on 10/08/2024 04:24 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 10/08/2024 at 04:00 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: LOVE HOME CARE FOR ELDERLY
FACILITY NUMBER: 198603596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

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 1 out of 2 residents which poses a potential health and safety risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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The licensee shall obtain a current physician's report for Resident #2 by POC due date 10/29/24.
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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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