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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603687
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:09:06 PM

Document Has Been Signed on 01/09/2024 12:09 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:ART OF LIVING SILVERTOWNFACILITY NUMBER:
198603687
ADMINISTRATOR:KIM, HYO SOOKFACILITY TYPE:
740
ADDRESS:15431 GARO STREETTELEPHONE:
(213) 820-3244
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 0DATE:
01/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Applicant Hyo Sook Kim TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an announced pre-licensing visit and met with Applicant Hyo Sook (Monica) Kim. The purpose of the visit was discussed.

An application for an Initial License was submitted to the department on 9/13/23. The facility will operate as a Residential Care Facility for the Elderly (RCFE). The facility has a total capacity to serve up to six (6) Residents. Fire clearance approved for six (6) residents who may be non-ambulatory, of which up to three (3) may be bedridden. Fire clearance for bedridden residents may be in Rooms #2-#4. Hospice Waiver approved for up to six (6) residents in care. Dementia care plan is in place.

The facility is a single-story home: Total of (9) bedrooms of which #1-#6 is for residents only and #7-#9 are staff break rooms and office spaces, (3) bathrooms, dining room, (2) living rooms, backyard with locked detached garage, and a laundry area. The physical plant was toured.

Pre-Licensed Inspection Tool was used.
The following was observed/inspected:

· There is a locked storage area that is centrally located for medication.

· Cleaning supplies are kept separate from food and located in a locked cabinet.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguishers and smoke/CO2 detectors operate properly.

· Doors and passageways are free of obstruction.

· There are no pools/bodies of water at the facility.

· Facility does not have firearms on premises.

(Continued on 809-C)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ART OF LIVING SILVERTOWN
FACILITY NUMBER: 198603687
VISIT DATE: 01/09/2024
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· All Required Postings were observed.

· There is an emergency exiting plan with emergency phone numbers posted.

· Facility has a current Emergency disaster plan maintained at the facility.

· Operating telephone is on the premises and will be available to residents.

· Locked area for Staff and Residents files observed..

· First-aid supplies are maintained and readily available.

· Refrigerator and freezer were observed and are maintained at the correct temperatures.

· Food storage and preparation are clean and appropriate for food preparation.

· Hot water temperature was tested and is within the required range of 105-120 degrees F.

· Plan of Operation / Dementia Care Plan / Infection Control Plan observed

Facility plant cleared on todays visit. Component III was completed with Applicant Monica Kim as well.

An exit interview was conducted, and a copy of this report has been furnished to applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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