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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607476
Report Date: 10/19/2020
Date Signed: 10/19/2020 03:04:02 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200715094716
FACILITY NAME:VISTA COVE AT ARCADIAFACILITY NUMBER:
197607476
ADMINISTRATOR:NOEMI BIELYFACILITY TYPE:
740
ADDRESS:601 SUNSET BOULEVARDTELEPHONE:
(626) 447-0106
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:130CENSUS: 70DATE:
10/19/2020
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Noemi Biely, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Noemi Biely, the facility administrator. LPA conducted the initial virtual complaint visit on 7/21/20.

The investigation consisted of the following: The physical plant was toured virtually during the initial complaint visit. Interview was also conducted with the administrator. LPA obtained an inspection report completed by CBRE (Assessment and Consulting Services)

The investigation revealed the following: The physical plant tour included the following: Kitchen, resident rooms (102,105, 208, 231), laundry rooms, dining/activity room, medication room, elevators, courtyard and front entrance.
Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
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 4
Control Number 28-AS-20200715094716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VISTA COVE AT ARCADIA
FACILITY NUMBER: 197607476
VISIT DATE: 10/19/2020
NARRATIVE
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Resident room 208 had paint peeling and cracking on the door that leads to the outside patio. Administrator said it's due to a water leak. Resident room 102 is directly below room 208 and also has the same peeling/cracking paint in the same location. A section of the first floor hallway wall had a leak that was repaired approximately 2 or 3 weeks ago according to administrator. However, the drywall has not been installed so the plumbing is exposed.

The inspection report completed by CBRE list moisture intrusion which has caused damage inside the facility. The report shows a picture of a hole in the ceiling of a room. This is contributing to the moisture intrusion throughout the building. Report shows pictures of windowsills with cracked adhesive. Report states moisture damaged drywall was observed throughout the building as a result of moisture intrusion and past piping leaks. Report indicates one resident bedroom had a note indicating the call box was not operable at the time of inspection. Report recommended the system be replaced.

Based on interviews conducted, documents reviewed, and observations made, the preponderance of evidence standard has been met. Therefore, the allegation is substantiated. The following deficiency was cited per California Code of Regulations, Title 22. Refer to 9099D. Exit interview held with administrator. A copy of the report and appeal rights were emailed to administrator for signature.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20200715094716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA
FACILITY NUMBER: 197607476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2020
Section Cited
CCR
87303(a)
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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.
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Administrator indicated a lot of the issues have been repaired or are in the process. Administrator will send receipts and contractors information by POC due date.
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This deficiency was evidenced by the following: LPA observed peeling/cracking paint in resident rooms. First floor hallway wall had a leak that was repaired, but the drywall was not replaced. Inspection report indicates moisture throughout the facility. Report recommended the call system in residents’ rooms be replaced.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200715094716

FACILITY NAME:VISTA COVE AT ARCADIAFACILITY NUMBER:
197607476
ADMINISTRATOR:NOEMI BIELYFACILITY TYPE:
740
ADDRESS:601 SUNSET BOULEVARDTELEPHONE:
(626) 447-0106
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:130CENSUS: 70DATE:
10/19/2020
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Noemi Biely, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility does not have a current license.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Noemi Biely, the facility administrator. LPA conducted the initial virtual complaint visit on 7/21/20.

The investigation consisted of the following: Allegedly facility does not have a current license due to situations regarding the lease. However, facility does have a current and valid license with Community Care Licensing. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
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 4