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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603790
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:57:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240828160538
FACILITY NAME:ALHAMBRA VILLAFACILITY NUMBER:
198603790
ADMINISTRATOR:KIM, HYO SOOKFACILITY TYPE:
740
ADDRESS:528 HOWARD STREETTELEPHONE:
(213) 820-3244
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:14CENSUS: 14DATE:
08/30/2024
UNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Evangelina Reyes, StaffTIME COMPLETED:
01:58 PM
ALLEGATION(S):
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Unlicensed care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the allegation above. LPA met with Staff Evangelina Reyes and discussed the purpose of the visit. LPA called operator Hyo Sook Kim and discussed the conversation she had with the Department on 08/28/2024 where Hyo Sook Kim admitted to operating without a License.

The investigation consisted of reviewing staff and resident rosters, and interviews with Applicant Hyo Sook Kim and staff Evangelina Reyes.

The investigation revealed: Applicant Hyo Sook Kim has applied for new License at current address Evergreen Senior Care 197608072. Applicant Hyo Sook Kim stated she is running the day to day operations of the facility without an approved License. There are 14 residents that require elements of care and supervision at the facility. There is sufficient evidence to substantiate the allegation.
(continued on 809C)


Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20240828160538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: ALHAMBRA VILLA
FACILITY NUMBER: 198603790
VISIT DATE: 08/30/2024
NARRATIVE
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Based on LPAs observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6.

Notice of Violation letter issued.

Exit interview was conducted, a copy of this report and Appeal Rights were provided to Evangelina Reyes
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240828160538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: ALHAMBRA VILLA
FACILITY NUMBER: 198603790
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2024
Section Cited
HSC
1569.44
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(a) A facility shall be deemed to be an “unlicensed residential care facility for the elderly” and “maintained and operated to provide residential care” if it is unlicensed and not exempt from licensure, and any one of the following conditions is satisfied:

(1) The facility is providing care and supervision, as defined by this chapter or the rules and regulations adopted pursuant to this chapter.

(2) The facility is held out as, or represented as, providing care and supervision, as defined by this chapter or the rules and regulations adopted pursuant to this chapter.

(3) The facility accepts or retains residents who demonstrate the need for care and supervision, as defined by this chapter or the rules and regulations adopted pursuant to this chapter.

(4) The facility represents itself as a licensed residential facility for the elderly.
This requirement was not met as evidenced by:
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The unlicensed operator shall either cease operation of the unlicensed facility or submit an application to the licensing agency within 15 calendar days. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted, operations cease, or relocate R1-R14 and provide relocation information.

Operator has submitted application for Facility License on 07/05/2024
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Current operator Kim, Hyo Sook stated she has taken over day to day operations of Evergreen Senior Care without an approved License. LPA observed Residents #1-#14 require elements of care and supervision. This poses a potential risk to the health and safety of the residents in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3