198603354-10-8-2021-28-AS-BTAO-C7LRLN-20211008130724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603354
Report Date: 10/08/2021
Date Signed: 10/08/2021 01:07:37 PM

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) 662-7101
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91006
CAPACITY:	6	CENSUS: 6	DATE:	10/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jennifer Sandoval, House Manager Vanessa Ricchiazzi (Carrillo-Rangel), Consultant Kenny Yu, Co-Manager		TIME COMPLETED:	12:15 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	Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met House Manager, Jennifer Sandoval, and Consultant, Vanessa Ricchiazzi and explained the purpose of the visit. Co-manager, Kenny Yu, joined the visit 30 mins after. The facility has a capacity of six (6). Its fire clearance is approved for five (5) non-ambulatory, one (1) bedridden and six (6) hospice waivers. Current resident census is six (6). No resident is on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is located in a residential area. A physical tour is conducted. The facility is 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 kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops were in working condition. Residents' bedrooms have dresser, chair and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 118.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. (-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: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

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: 10/08/2021

NARRATIVE

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Dual combos which smoke detector is combined with carbon monoxide detector are operable and hard wired. Fire extinguishers are fully charged and last service is on 7/28/2021. Auditory device is operable. The first aid kit is fully stocked. The last Fire/ Emergency Drill was conducted on 6/20/21. All mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents. There are no pools and bodies of water on the premises. There are no firearms on the premises. Facility maintains a comfortable temperature of 74 degrees Fahrenheit for residents.

Administrator certificate is current and the expiration date is 7/29/2023.

No deficiencies cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Consultant, Vanessa Ricchiazzi (Carrillo-Rangel), whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

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