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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603354
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:50:17 PM


Document Has Been Signed on 10/27/2023 03:50 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ASSISTED LIVING & WELLNESSFACILITY NUMBER:
198603354
ADMINISTRATOR:YU, DAVIDFACILITY TYPE:
740
ADDRESS:608 WEST PALM DRIVETELEPHONE:
(626) 662-7101
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:6CENSUS: 6DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:David Yu, administratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with David Yul at the facility and spoke with Consultant, Vanessa Ricchiazzi via Facetime. LPA explained the purpose of the visit.

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). One (1) resident is on hospice. During the visit, CARE tool was used, a tour of the facility was conducted, food supply was reviewed, staff/residents records reviewed and medications were reviewed.

The facility is located in a residential area, 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. Two (2) days perishable and seven (7) days non-perishable area observed. Residents' rooms, common areas, bathrooms and kitchen have the required furnishing and in compliance. Hot water temperature is 117.5 degrees Fahrenheit which is 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 was operable. All mandated documents and signages are posted in common areas. Medication records are current. Medication, resident / staff records are stored in a locked storage room and inaccessible to residents. Administrator certificate is current and the expiration date is 11/30/2024.

No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to David Yu, administrator.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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