198603354-9-24-2020-28-AS-BTAO-BTRL6A-20200924082823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603354
Report Date: 09/17/2020
Date Signed: 09/24/2020 08:29:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	ASSISTED LIVING & WELLNESS		FACILITY NUMBER:	198603354
ADMINISTRATOR:	YU, DAVID		FACILITY TYPE:	740
ADDRESS:	608 W. PALM DRIVE		TELEPHONE:	(626) 315-2561
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91006
CAPACITY:	6	CENSUS: 0	DATE:	09/17/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	David Yu, applicant		TIME COMPLETED:	01:00 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	Licensing Program Analysts (LPAs), Tao and Chavez conducted an announced pre-licensing inspection. This is an initial application. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing inspection was conducted telephonically with Administrator and staff. LPAs met David Yu, licensee applicant, and Kenny Yu, applicant's brother at the virtual visit. The facility has a capacity of six (6). Its fire clearance is approved for five (5) non-ambulatory and one (1) bedridden. LPA observed zero resident at the time of the visit. The applicant is an incorporation, Assisted Living & Wellness Inc. The facility was a single-story home with six (6) client’s bedrooms, three (3) bathrooms, a living room, a kitchen, a dining room, an activity area, a laundry room and a garage. The facility was located in a residential neighborhood. This facility was granted a fire clearance on July 14, 2020. LPAs took a virtual tour for the physical plant including the inside and outside of the house. LPAs observed the following: -Food storage and preparation areas were clean and in good repair. -Cooking / kitchen appliances were operational -Food utensils and dining wares were sufficient for its capacity. -Hot water was 110 degrees Fahrenheit which was within Title 22 Regulation guidelines. -Dishwashing soap/ detergents were stored in a locked cabinet and inaccessible to clients. -A refrigerator was maintained at 32 degrees Fahrenheit and the freezer was maintained 0 degree Fahrenheit -Two days of perishable food and seven days of non-perishable food were available. -Sharp tools and knives were stored in locked drawers in the kitchen. -A locked cabinet for cleaning supplies and poisons solutions, -Medication was centrally stored in a medication room and inaccessible to residents. (- continued in LIC 809-C -)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASSISTED LIVING & WELLNESS	FACILITY NUMBER: 198603354
	VISIT DATE: 09/17/2020

NARRATIVE

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-Two fire extinguishers were fully charged which were located in the kitchen and hallway. The last service date was 07/25/2020.
-Facility had central air and heating accommodations.
-Smoke and carbon monoxide detectors were operational.
-Linens supplies and personal hygiene supplies were adequate.
-Residents’ bedrooms were inspected for personal accommodations for safety, privacy, and comfort.
-Residents’ rooms were well furnished and in compliance.
-Grab bars are maintained for each toilet, bathtub and shower.
-Non- skid mats are installed in bathtubs and showers.
-Doors, stairways and passageway were unobstructed,
-Facility was in good repair with a TV in the living room.
-No pool or bodies of water in the facility
-A phone for residents was operational.
-First aid supplies and first aid manual were maintained
-Outdoor activity area, supplies, shaded area, chairs were furnished and in compliance.
-Administrators had Criminal Background Clearance
-Personnel Report / LIC 500 were prepared. Licensee applicant stated that the staff records/ files would be updated when needed and more staff are hired.
-A current disaster plan was maintained
-The backyard was consisting of a shaded area with patio furniture.
-All emergency shut-offs are located on the side of the house.
-Auditory device at the main entrance, exit doors and windows are operable.
-All emergency shut-offs are located on the side of the house.
-Auditory device at the main entrance, exit doors and windows are operable.
Component III was conducted during this visit.

Corrections needed:
Installing ramp for the steps at the backyard.
Posting Labor law information as required by law.

An exit interview was conducted and a copy of this report was provided to Applicant, David Yu.
The applicant will notify the department once the ramp is installed and labor law is posted

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC809 (FAS) - (06/04)

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