198603354-10-11-2022-28-AS-ALOZ-CK53P5-20221011182454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603354
Report Date: 10/11/2022
Date Signed: 10/11/2022 06:27:13 PM

Document Has Been Signed on 10/11/2022 06:27 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
GREATER LA AC/SC, 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 WEST PALM DRIVE		TELEPHONE:	(626) 662-7101
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	6	CENSUS: 6	DATE:	10/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:29 PM
MET WITH:	Vannesa Ricchiazzi, Assstant Administrator		TIME COMPLETED:	04:49 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) Alberto Lopez conducted an unannounced annual inspection visit. LPA was greeted by Silvia Deleon DSP and with met Assistant Administrator Vanessa Ricchiazzi who arrived a short time later and LPA explained the purpose of the rvisit. The facility has a capacity of six (6). Its fire clearance is approved for five (5) non-ambulatory, one (1) bedidden 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 in a residential area. A physical tour was 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 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 99.9 in one tub and kitchen dispenser was 159.1 degrees Fahrenheit which was not within Title 22 Regulation guidelines. Dual combos which smoke detector is combined with carbon monoxide detector are operable and hard wired. Fire extinguishers are fully charged. Auditory device is operable. The first aid kit is fully stocked. The last Fire/ Emergency Drill was conducted on 8/21/22. All mandated documents and signs are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked storage room and inaccessible to residents.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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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Document Has Been Signed on 10/11/2022 06:27 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASSISTED LIVING & WELLNESS	FACILITY NUMBER: 198603354
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the licensee did not comply with the section cited above as water was measured at 99.9 degrees in one Tub and 159.9 degress F in the drinking water dispenser in the kitchen which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Administrator will adjust water temperture to be within range of 105-120 degress F, certify and send proof to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASSISTED LIVING & WELLNESS	FACILITY NUMBER: 198603354
	VISIT DATE: 10/11/2022

NARRATIVE

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rResident 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.

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

Deficiencies cited per California Code of Regulations, Title 22. (please see 809D for details)

An exit interview was conducted. This report was discussed and provided via email to facility Assistant Administrator, Vanessa Ricchiazzi. (Due to printer not functioning, report is to be emailed to: vpr.projectmanager@gmail.com

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

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