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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603687
Report Date: 09/03/2024
Date Signed: 09/03/2024 12:12:57 PM

Document Has Been Signed on 09/03/2024 12:12 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/
DIRECTOR:		KIM, HYO SOOKFACILITY TYPE:
740
ADDRESS:15431 GARO STREETTELEPHONE:
(213) 820-3244
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 6DATE:
09/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:staff Eun Kee ByunTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted Case Management - Deficiencies visit as a result of observed deficiency during POC visit on the same day. LPA met with staff Eun Kee Byun and explained the purpose of this visit as well as explained to administrator Hyo Kim via phone call.

During the visit, LPA Villalobos observed residents #1 and #2 to be living in a room designated as a staff room.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 1. Immediate Civil Penalty is being assessed. See attached 809-D page.

Exit interview was conducted, appeal rights discussed. A copy of this report and the appeal rights were also provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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 09/03/2024 12:12 PM - It Cannot Be Edited


Created By: Jose Villalobos On 09/03/2024 at 11:52 AM
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: 09/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2024
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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Facility to relocate residents to approved resident rooms by POC due date. LPA to conduct follow up visit to verify.
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This was not met as evidenced by:
Resident #1 and Resident #2 were living in a room designated as a staff room not cleared for resident occupation, this poses an immediate health and safety risk to residents in care and supervision.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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