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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603483
Report Date: 09/21/2021
Date Signed: 09/22/2021 08:43:39 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 - NAOMIFACILITY NUMBER:
198603483
ADMINISTRATOR:YU, DAVIDFACILITY TYPE:
740
ADDRESS:220 W. NAOMI AVETELEPHONE:
(626) 315-2561
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:6CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:David Yu, Applicant
Kenny Yu, House Manager		TIME COMPLETED:
03:35 PM
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On 09/21/21, the Monterey Park Adult and Senior Care Office conducted a virtual informal conference with Applicant David Yu of the corporation: ASSISTED LIVING & WELLNESS INC. along with the Centralized Application Bureau (CAB) to discuss the pending application, licensing process, compliance with Title 22 Regulations and the Health & Safety Code, as it has been determined that the location is operating without an approved license from the Department.

Conference Participants:
David Yu, Applicant
Kenny Yu, House Manager
Paul Ricchiazzi, Consulting Manager
Vanessa Ricchiazzi, Consulting Manager
Hao Nguyen, Chief of Centralized Application Bureau
Darla Neeley, Centralized Application Bureau, Staff Services Manager I
Michael Barraza, Centralized Application Bureau, Staff Services Analyst
Araceli Ramirez, Community Care Licensing, Regional office Manager
Fernando Fierros, Community Care Licensing, Licensing Program Manager
Bonnie Tao, Community Care Licensing, Licensing Program Analyst.

The purpose of this informal conference is to ensure the Applicant understands the licensing process and unlicensed care as it relates to Title 22 Regulations and the Health & Safety Code to ensure the safety of any and all residents in care. (-Continued in LIC 809C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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: 09/21/2021
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The Applicant agreed to abide and comply with Title 22 regarding operating a Community Care Facility for the Elderly.

The Applicant applied for licensure with the department on 05/03/2021 and the application is pending. A Fire Clearance has been granted for five (5) bedridden and one (1) ambulatory resident.

During the conference, the following was discussed.


The current census is four (4) elderly residents, of which three (3) residents are currently receiving hospice care and each resident has a nurse onsite 24 hours a day, 7 days a week and one (1) resident who has dementia is residing at the location and has a Home Care Aide from 7AM to 7PM. After 7PM a staff who is hired by the Applicant provides supervision to the resident until 7AM. Medications for the four (4) residents are being centrally stored at the location.

Applicant, David Yu confirmed that the Centralized Application Bureau (CAB) was NOT notified that the location is retaining four (4) residents while the application is pending licensure. House Manager, Kenny Yu, confirmed facility is applying for a Dementia Wavier and Hospice Waiver.

The following items were also discussed, and copy was emailed to the Applicant David Yu for review:
Health & Safety Code 1509 -Inspection, licensure and approval
Health & Safety Code 1547 Violation of sections 1503.5 or 1508, civil penalty, appeal,
Health & Safety Code 1503.5 Unlicensed community care facility; definition; operation prohibited; procedure upon discovery
Health & Safety Code 1508. Necessity of License; special permit community care facility, local public agency
(-Continued in LIC 809C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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: 09/21/2021
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Section 87455 Acceptance and Retention Limitation
Section 87609 Allowable Health Conditions and the Use of Home Health Agencies
Section 87615 Prohibited Health Conditions
Section 87606 Care of Bedridden residents.
Section 87633 Hospice care of Terminally III Residents
Section 87705 Care of Persons with Dementia
Section 87632 Hospice Care Waiver

During meeting, the Applicant David Yu was advised to not accept new admission during the application process, as the location is not licensed. The Applicant David Yu confirmed the location will not retain additional residents and will not admit new residents.



LIC 809 dated 09/21/21 was emailed to Applicant David Yu for review and signature.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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