198603483-9-17-2021-28-AS-BTAO-C6XSLQ-20210917135845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603483
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:58:59 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 - NAOMI		FACILITY NUMBER:	198603483
ADMINISTRATOR:	YU, DAVID		FACILITY TYPE:	740
ADDRESS:	220 W. NAOMI AVE		TELEPHONE:	(626) 315-2561
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	6	CENSUS: 4	DATE:	09/17/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	David Yu, applicant Kenneth Yu, assistant Vanessa Ricchiazzi, consulting manager		TIME COMPLETED:	02:00 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 Analyst (LPA) Tao conducted an announced pre-licensing inspection. This is an initial application applying for Residential Care for Elderly to serve residents for age 60 and above. LPA met with David Yu, applicant, Kenneth Yu, assistant, and Vanessa Ricchiazzi, consulting manager. The requested capacity is 6. Resident census is four (4). The licensee is Assisted Living & Wellness Inc. Facility has a Dementia Care program. Fire clearance: Fire clearance was granted on 5/28/21 for five (5) bedridden and one (1) ambulatory. Fire clearance has a note stating Room #2, #3, #1, #5 and #6 granted clearance for bedridden. Dementia resident is admitted. Dementia care plan is in place. Auditory device is installed at the front door. Structure: The property is a single-family residence located in a neighborhood, consisting of six (6) bedrooms, three (3) bathrooms, kitchen, dining room, and living room with a TV. Passageways, walkways, stairs and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Signal system and Garage: Facility does not have a signal system. Garage is not accessible to residents. Bedrooms for Residents: Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Currently, Bedroom #1, #2, #5 and #6 have a resident residing. (- Continued 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: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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 - NAOMI	FACILITY NUMBER: 198603483
	VISIT DATE: 09/17/2021

NARRATIVE

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Bathrooms:
Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower.

Linens & Hygiene Supplies:
Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash cloths and towels are observed.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Medications, First-Aid Kit & Book:
Medication cabinet is installed with a lock and inaccessible to residents.
First aid kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze.
First Aid manual from American red cross was available for staff use and inaccessible to residents.

Smoke Detectors:
Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators, one is the kitchen and one additional refrigerator in the garage for food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source. (-Continued 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: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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 - NAOMI	FACILITY NUMBER: 198603483
	VISIT DATE: 09/17/2021

NARRATIVE

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Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted near the entrance. Exit Plan are available for review.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Residents & Staff Files:
Locked cabinets for records of staff and clients are installed and available. Residents file are observed. Applicant will not handle cash resources for residents.

Water Temperature:
Tested at 116.5 degrees Fahrenheit.

Menu and phone:
Menus are available for review.
Free landline telephone is available for residents’ use and operable.

Fire extinguishers:
Fire extinguishers are available in the facility. One is located on the first floor near kitchen mounted on wall and the other one is located at the garage. They are fully charged and last service was done in 7/30/2021.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials for the residents’ use and commensurate with the plan of operation.

Pool:
No bodies of water located at the facility.

No issue was observed during today’s visit.

(-Continued 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: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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 - NAOMI	FACILITY NUMBER: 198603483
	VISIT DATE: 09/17/2021

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Exit:

Applicant requested to waive Component III since applicant has done component III from the pre-licensing of other facilities. Therefore, Component III was not conducted during this visit.

An informal conference with Licensing and Centralized Application Bureau is confirmed with David Yu, Kenneth Yu, Paul Ricchiazzi, and Vanessa Ricchiazzi. Informal conference is scheduled on September 21, 2021, 2:30pm-3:30pm.

A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC809 (FAS) - (06/04)

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