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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601410
Report Date: 08/16/2023
Date Signed: 08/16/2023 07:11:19 PM


Document Has Been Signed on 08/16/2023 07:11 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:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Lulin 'Lucy' Wu/AdministratorTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Unusual Incident Report (UIR) for resident (R1) submitted by the facility to the Department on June 27, 2023. LPA met with Lulin 'Lucy' Wu, administrator, and licensees, Wendy Wong and Olive Manalastas, and informed the reason for visit

UIR indicated that on June 26, 2023 at 8:30 am. staff was going to help resident (R1) with morning grooming and noticed R1 unresponsive. Staff immediately called 9-1-1, and started CPR. At 8:45 am, the paramedics pronounced time of death. Police Officer arrived at the facility, took report. and called Coroner's Office. Coroner grant the release of R1's body. R1's son and daughter came to the facility, and called the mortuary.

On this day, August 16. 2023, LPA reviewed R1's records including but not limited to LIC602A Physician's Report, doctor's order of medications and Medication Administration Record. LPA obtained copies of documents and conducted interviews.

No deficiency cited during today's visit.

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: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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