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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601410
Report Date: 08/31/2022
Date Signed: 08/31/2022 07:22:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2020 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20201223144831
FACILITY NAME:ARCADIAN RESIDENTIAL COMMUNITYFACILITY NUMBER:
015601410
ADMINISTRATOR:NELSON MASAYAFACILITY TYPE:
740
ADDRESS:24647 MOHR DRIVETELEPHONE:
(510) 887-8898
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:40CENSUS: 40DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Lulin "Lucy" Wu/AdministratorTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Lulin "Lucy" Wu, administrator, and informed the purpose of visit. LPA also met with licensees, Wendy Wong and Olive Manalastas. The licensees have to leave and excused themselves after about an hour.

During the course of investigation, LPAs Hamitlon and Delmundo obtained copies of staff schedule and LIC9020 Register of Facility Residents, R1's documents including but not limited to LIC602A Physician's Report, Admission Agreement, LIC601 Identification and Emegency Contact Information. LPAs conducted interviews and inspection.


.....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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 5
Control Number 15-AS-20201223144831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/31/2022
NARRATIVE
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During the 10-complaint visit, LPA Hamilton conducted inspection and noted that while touring R1's former bathroom, LPA observed some discoloration within the medicine cabinet as well as the tile grout near the base of the toilet. LPA observed a section of the wall directly behind the toilet was uneven. S1 stated the area was worked on 3 years ago to repair a leak.

LPA Delmundo conducted inspection on this day, August 31, 2022, with Lulin Wu. LPA randomly selected 6 residents' rooms and toilets/showers for inspection. LPA observed the following in 5 of 6 rooms: missing baseboards in 2 rooms; part of flooring chipped; rusted bathroom lavatories; grab bar missing in the shower room; peeled bathroom door paint

Based on observation, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations and listed on LIC9099D. 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 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: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20201223144831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
-This requirement in not met as evidenced by:

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Administrator stated she'll have the items fixed and/or replaced/repaired. In additiion, adminitrator to check all other rooms and areas in the facility, and repairs done when needed. Pictures to be submitted by 09/14/2022.
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-Based on inspection, the licensee did not comply with the section above in 5 out of 6 rooms that were observed in disrepair which pose personal rights risks to persons 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2020 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20201223144831

FACILITY NAME:ARCADIAN RESIDENTIAL COMMUNITYFACILITY NUMBER:
015601410
ADMINISTRATOR:NELSON MASAYAFACILITY TYPE:
740
ADDRESS:24647 MOHR DRIVETELEPHONE:
(510) 887-8898
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:40CENSUS: 40DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Lulin "Lucy" Wu/AdministratorTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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-Facility is unsanitary.

-Facility staff did not provide to resident's responsible party resident's (R1) personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Lulin "Lucy" Wu, administrator, and informed the purpose of visit. LPA also met with licensees, Wendy Wong and Olive Manalastas. The licensees have to leave and excused themselves after about an hour.

During the course of investigation, LPAs Hamitlon and Delmundo obtained copies of staff schedule and LIC9020 Register of Facility Residents , R1's documents including but not limited to LIC602A Physician's Report, Admission Agreement, LIC601 Identification and Emegency Contact Information, LIC 621 Resident Personal Property Valuables. LPAs conducted interviews and inspection.


......continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20201223144831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/31/2022
NARRATIVE
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Allegation: Facility is unsanitary.
It was alleged that R1's room was unsanitary; there were cobwebs on the walls above R1's head, dried blood on R1's bed sheet and the bottom of the dresser was filthy.

R1's family member (FM) was interviewed and stated that R1's room was unsanitary. When FM picked-up R1's belongings after R1 passed away, R1's hat was covered with mold.

LPA Hamilton noted during his 10-day complaint visit that there's no obvious signs of unsanitary conditions.

On this day, August 31, 2022, LPA Delmundo conducted inspection with Lulin Wu. LPA inspected the common areas, randomly selected 6 residents' room and bathrooms/shower, kitchen, dining area and storage. LPA did not observed any cobwebs and mold, nor facility being unsanitary. LPA interviewed S2 and S3 who both indicated that when R1 passed away, they packed R1's belongings and put them in boxes and bag and stored them in the storage until FM picked them up. They did not inspect the boxes and bag prior to handling them over to FM about a month after R1's death. LPA tried to interview R1's room mate who refused to be interviewed.

Allegation: Facility staff did not provide to resident's responsible party resident's (R1) personal belongings. It was alleged that when R1's belongings were picked-up after R1's death, the wheelchair and walker were not given and photograph of R1's family member was not included with R1's belongings.

LPAs Hamilton and Delmundo conducted interviews and obtained copies of LIC621, Staff S2 and S3 stated that when FM came to the facility to pick-up R1's belongings, they assisted FM in loading the items in FM's vehicle including the wheelchair and walker. S2 indicated she did not see the picture FM indicated missing when they packed-up R1's belongings. LPA reviewed the LIC621 which revealed the items which were allegedly missing were not listed.

Based on the information obtained, the allegations are deemed unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited. Exit interview conducted 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: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5