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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601410
Report Date: 06/29/2024
Date Signed: 06/29/2024 04:10:26 PM


Document Has Been Signed on 06/29/2024 04:10 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: 40DATE:
06/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Wendy Wong/Licensee and
Rachel Estares Maniaul/Assistant Administrator 		TIME COMPLETED:
04:15 PM
NARRATIVE
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At 10:30 a.m. on this day, June 29, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Rachel Estares Maniaul, assistant administrator, and informed the reason for visit. LPA called and spoke over the phone with Wendy Wong, licensee. Licensee arrived at 10:46 a.m, and Lulin Wu, administrator, arrived at 2:45 p.m.

Facility has LIC9282 Infection Control Plan that was submitted and received by LPA on June 28, 2022.

LPA toured the facility inside out with the assistant administrator, and joined by licensee. LPA inspected the kitchen, dining room, living room, reception area, shower room, ensuite bathrooms/toilets, front, side and backyards. LPA randomly selected 8 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 and storages for cleaning supplies were observed locked.

Facility has smoke and carbon monoxide detectors in operating condition. Hot water temperature in one of the ensuite toilets was tested. Facility conducts drills every quarter, and records showed last conducted June 4, 2024. Fire extinguishers were observed fully charge with tags showed serviced February 26, 2024.

LPA reviewed 5 staff and 5 residents files, and interviewed 3 staff and 3 residents. Facility handles 6 of residents' P&I/allowance according to the assistant administrator. P&I money checked and compared with last recorded balance. Medications checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record.

...continued on 809C (page 2)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024
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 4


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: 06/29/2024
NARRATIVE
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Page 2

LPA observed the following:
-at 11:32 a.m., hot water in ensuite bathroom at 101.5 degrees Fahrenheit.
-at 12:30 pm, resident (R1) LIC602A Physician's Report indicated bedridden. R1 can not reposition without assistance, and facility is not fire cleared/licensed for bedridden.

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. A $500.00 civil penalty is assessed for deficiency section # 87202(a)(2).

Deficiencies and plan and proof of corrections were discussed with the licensee, administrator and assistant administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessement, 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: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/29/2024 04:10 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: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in R1 being bedridden and facility is does not have bedridden fire clearance which poses an immediate health, safety and/or personal rights risk to person in care.
POC Due Date: 06/30/2024
Plan of Correction
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Corrected.
Licensee called the resident's responsible person then sent the resident out while LPA was at the facility.
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: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/29/2024 04:10 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: 06/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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 in hot water at 101.5 degrees Fahrenheit ] which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Corrected.
Licensee have the maintenance staff adjust the temperature to 108 degrees Fahrenheit while LPA was at the facility.
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: 06/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4