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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601410
Report Date: 07/06/2022
Date Signed: 07/06/2022 05:30:13 PM


Document Has Been Signed on 07/06/2022 05:30 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ARCADIAN RESIDENTIAL COMMUNITYFACILITY NUMBER:
015601410
ADMINISTRATOR:LULIN WUFACILITY TYPE:
740
ADDRESS:24647 MOHR DRIVETELEPHONE:
(510) 887-8898
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:40CENSUS: 39DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lulin Wu/Administrator, Wendy Wong/Licensee
and Olive Manalastas/Licensee		TIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with Lulin Wu, administrator, and informed the purpose of visit. LPA also met with Wendy Wong and Oilive Manalastas, licensees.

Facility has an approved LIC808 Mitigation Plan on file. Administrator submitted the facility's new Infection Control Plan and received by LPA Delmundo on June 28, 2022.

LPA toured the facility inside out with Lulin Wu. LPA inspected the living room, dining area, kitchen, hallways, side and backyard. LPA randomly selected 7 bedrooms for inspection. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe and Visitor's Log. Visitor's temperature and symptom checks are done at the entrance. Residents and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked and observed adequate for 30 days, and antigen test kits are readily available. COVID-19 signages were observed throughout the facility. Trash bins were observed with foot pedal operated lids. Bathroom lavatories were observed with liquid soap and paper towels in dispensers. Some of the staff were fit tested for N95 respirator last year, Juiy 8, 2021. LPA verified, and Lulin stated some staff have been re-fit tested while others are scheduled for re-testing.

Fire extinguishers checked and observed fully charge with tags showed serviced February 16, 2922. Hot water temperature in one of the common bathrooms was tested and measured at 106.6 degrees Fahrenheit.
First aid kit inspected and observed complete with manual.
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.....continued next page
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ARCADIAN RESIDENTIAL COMMUNITY
FACILITY NUMBER: 015601410
VISIT DATE: 07/06/2022
NARRATIVE
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At 3:36 PM, LPA observed unlocked storage in the backyard where cleaning supplies are kept.

The following updated/current documents were provided to LPA on this same day:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Olive Manalastas and Lulin Wu.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/06/2022 05:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ARCADIAN RESIDENTIAL COMMUNITY
FACILITY NUMBER: 015601410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients

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. Storage where cleaning supplies are kept was observed unlocked which poses an immediate health and safety risks to persons in care.
POC Due Date: 07/07/2022
Plan of Correction
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Staff locked the storage while LPA was at the facility.
Licensee and adminisrator stated staff will be in-serviced. Proof to be submitted by 7/07/2022.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3