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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198603687
Report Date:
08/22/2024
Date Signed:
08/22/2024 03:44:52 PM
Document Has Been Signed on
08/22/2024 03:44 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 SILVERTOWN
FACILITY NUMBER:
198603687
ADMINISTRATOR/
DIRECTOR:
KIM, HYO SOOK
FACILITY TYPE:
740
ADDRESS:
15431 GARO STREET
TELEPHONE:
(213) 820-3244
CITY:
HACIENDA HEIGHTS
STATE:
CA
ZIP CODE:
91745
CAPACITY:
6
CENSUS:
10
DATE:
08/22/2024
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:
Administrator Hyo Kim
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos arrived unannounced to conduct an Post Licensing inspection. LPA met with staff Reina Rojas who allowed entry into the home. The purpose of the visit was discussed. Administrator Hyo Kim arrived shortly after.
The Facility is licensed 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 inspection was completed using the CARE tools.
Observations:
LPA toured and inspected a total of (9) rooms. Bedrooms #1-#6 was used for residents #1-#7 (R1-R7), Resident #8 (R8) is using the living room as their bedroom, and staff room was being used for Residents #9-10 (R9-R10). The facility is operating over its licensed capacity. LPA continued tour and observed (2) rooms used as a staff office and staff supply/break room. There are (3) bathrooms, (1) dining room, (2) living rooms, backyard with locked detached garage, and a laundry area. Sharps were observed secured in locked. The facility was free of odor, clean and in good repair. No obstructions were noted in hallways or living areas. Sufficient furniture and lighting was observed throughout the facility.
LPA reviewed plan of operation. personnel policies reviewed and discussed. Reporting requirements were discussed. This included abuse reporting procedures.
(10) Resident file records were reviewed. Resident files all had admissions agreements but missing various other documents such as physicians reports and appraisals.
Continued on LIC 809-C
SUPERVISORS NAME
:
Fernando Fierros
LICENSING EVALUATOR NAME
:
Jose Villalobos
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
7
Document Has Been Signed on
08/22/2024 03:44 PM
- It Cannot Be Edited
Created By:
Jose Villalobos
On
08/22/2024
at
02:06 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:
ART OF LIVING SILVERTOWN
FACILITY NUMBER:
198603687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited as LPA observed a total of (10) residents living in the facility. There were a total of (10) resident files that confirmed the same, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2024
Plan of Correction
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4
Licensee to create and follow plan of relocating residents until they reach the proper capacity they are licensed for by POC due date. LPA to conduct follow up visit to verify.
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above as Resident #9 was observed to be using rhe living room as a bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2024
Plan of Correction
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Facility to place Resident #9 in an approved bedroom or relocate resident to proper placement by POC due date. LPA Villalobos to conducted follow up visit to verify.
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:
Fernando Fierros
LICENSING EVALUATOR NAME:
Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
08/22/2024 03:44 PM
- It Cannot Be Edited
Created By:
Jose Villalobos
On
08/22/2024
at
02:06 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:
ART OF LIVING SILVERTOWN
FACILITY NUMBER:
198603687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Staff #1 observed working at the facility was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2024
Plan of Correction
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Administrator associated the staff via guardian during the visit. Deficiency cleared during the visit .
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as medications for Resident #7-#8 were observed in the common rooms away from the centrally stored medication cart which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2024
Plan of Correction
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4
Administrator placed medications in locked medications cart. 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.
SUPERVISOR'S NAME:
Fernando Fierros
LICENSING EVALUATOR NAME:
Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
08/22/2024 03:44 PM
- It Cannot Be Edited
Created By:
Jose Villalobos
On
08/22/2024
at
02:06 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:
ART OF LIVING SILVERTOWN
FACILITY NUMBER:
198603687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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 as medications for residents were popped out or removed from pill bottles and placed into weekly box containers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2024
Plan of Correction
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Facility to return medications to pill bottles contact pharmacy to disharge medications removed from bubble packs by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:
Fernando Fierros
LICENSING EVALUATOR NAME:
Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
08/22/2024 03:44 PM
- It Cannot Be Edited
Created By:
Jose Villalobos
On
08/22/2024
at
02:06 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:
ART OF LIVING SILVERTOWN
FACILITY NUMBER:
198603687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as no caregiver staff have first aid/ CPR certification on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/05/2024
Plan of Correction
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Administrator to aquire first aid and CPR training for all staff by POC due date. Copies will then be provided to LPA Villalobos.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
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 as there was not staff file for staff #1 and #3 for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/05/2024
Plan of Correction
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Administrator to complete staff files for Staff #1 and Staff #3. Files to be kept on hand in the facility for Licensing to review. Copies of the file to be provided to LPA by POC due date.
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:
Fernando Fierros
LICENSING EVALUATOR NAME:
Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
08/22/2024 03:44 PM
- It Cannot Be Edited
Created By:
Jose Villalobos
On
08/22/2024
at
02:06 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:
ART OF LIVING SILVERTOWN
FACILITY NUMBER:
198603687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility did not keep staff training records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/05/2024
Plan of Correction
1
2
3
4
Licensee/Administrator to begin logging staff in services and trainings by POC due date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Residents #1-2, and Residents #7-#10 do not have completed medical assessments on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/05/2024
Plan of Correction
1
2
3
4
Licensee/ Administrator to aquire or complete medical assessments for Residents #1-2 and Residents #7-#10 mentioned above by POC due date. Copies to be provided to LPA by POC due date
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:
Fernando Fierros
LICENSING EVALUATOR NAME:
Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
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:
08/22/2024
NARRATIVE
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(4) Staff records were reviewed. (2) Files requested by LPA were unavailable as they had not been created by the administrator. Per Title 22, All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
LPA checked criminal record clearances and staff #1 (S1) is not cleared or associated to this facility.
Centrally stored medications were reviewed. LPA observed R3, R7, and R8 to have medication out in common areas. Medications observed were also popped out and prepared into weekly boxes. In-service training's and medication procedures were not logged.
See Something Say Something complaint poster, Evacuation Routes and facility license were all posted as required.
Deficiencies noted and citations issued per the California Code of Regulations, Title 22, Division 6, Chapter 8, which includes immediate civil penalties. Please see the attached LIC 809D.
Immediate Civil Penalty was assessed. Per Title 22, Division 6 ,Chapter 8 (f) Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department. Civil Penalties were assess at $300 for this violation.
Additionally, immediate civil penalties were assessed in the amount of $500, due to a Fire Clearance Violation.
Exit interview conducted. Appeal rights were discussed with Administrator Hyo Kim. A copy of the report and appeal rights were provided.
SUPERVISORS NAME
:
Fernando Fierros
LICENSING EVALUATOR NAME
:
Jose Villalobos
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7