015601410-8-16-2023-15-AS-ADEO-CUS4TJ-20230816192314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601410
Report Date: 08/16/2023
Date Signed: 08/16/2023 07:23:21 PM

Document Has Been Signed on 08/16/2023 07:23 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 COMMUNITY		FACILITY NUMBER:	015601410
ADMINISTRATOR:	LULIN WU		FACILITY TYPE:	740
ADDRESS:	24647 MOHR DRIVE		TELEPHONE:	(510) 887-8898
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	40	CENSUS: 39	DATE:	08/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Lulin 'Lucy' Wu/Administrator		TIME COMPLETED:	07:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, August 16, 2023, at 11:40 a.m,, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Lulin 'Lucy' Wu, administrator, and informed the reason for visit. Wendy Wong and Olive Manalastas, licensees, arrived after about 40 minutes. Facility has Infection Control Plan that was submitted and received by LPA on June 28, 2022. LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining room, living room, reception area, shower room, ensuite bathrooms/toilets, front, side and backyards. LPA randomly selected 6 residents rooms for inspection. Shower room was observed equipped with bathing chair, non-skid mat and grab bars. Toilets were also observed with grab bars, paper towel in dispensers for drying hands and toiletries. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Storages in the yard where cleaning supplies are kept were all observed locked. Facility has smoke and carbon monoxide detectors in operating condition. Hot water temperature in one of the ensuite toilets was tested, and measured at 106 degrees Fahrenheit. Facility conducts drills every quarter, and records showed last conducted July 15, 2023.. LPA reviewed 5 staff and 5 residents files, and interviewed 3 staff and 3 residents. Facility handles 8 of residents' allowance according to the administrator. Cash checked and compared with record. Medications inspected and compared with records and doctor's orders. ....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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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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: 08/16/2023

NARRATIVE

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LPA observed the following:
-at 12:02 pm, uneven and cracked pavements on the side and backyards.
-at 4:00 pm, LPA observed resident (R3) has 1 medication listed on LIC602A but the facility does not have the medication. It's not clear whether or not the medication is still needed.

LPA received the following updated/current documents on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. LIC400 Affidavit Regarding Client/Resident Cash
5. Proof of Surety Bond Coverage
6. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed withthe licensees and administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/16/2023 07:23 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: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for R3 having doctor's order for a medication but facility does not have it which poses an immediate health risk to person in care.
	POC Due Date: 08/17/2023
	Plan of Correction
1 2 3 4	Administrator to obtain the medication if still needed by the resident; otherwise, obtain a discontinued order. Proof to be submitted by 8/17/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/16/2023 07:23 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: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation. the licensee did not comply with the section cited above fro uneven and cracked pavements on the side and backyard which poses a potential safety risk to persons in care.
	POC Due Date: 08/30/2023
	Plan of Correction
1 2 3 4	Licensees stated they will have the yard repaired. Piictures to be submitted by 8/30/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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