198603483-9-15-2021-28-AS-FFIS-C7532V-20210922175234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603483
Report Date: 09/15/2021
Date Signed: 09/15/2021 05:37:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210910144641

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:	09/15/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kenneth Yu, Co-manager Vanessa Ricchiazzi, consulting manager.		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Unlicensed care being provided.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Tao and Long conducted an unannounced initial complaint visit to the residence regarding the allegation of unlicensed care and. Upon arrival LPAs met with Kenneth Yu, co-manager and Vanessa Ricchiazzi, consulting manager and explained the purpose of the visit. Later, LPA Tao explained the purpose of visit during phone interview with David Yu, applicant.

An application for a residential Facility for Elderly was submitted to Community Care Licensing ane is pending for licensure. A Fire clearance was granted on 5/28/21 for 5 bedridden and 1 ambulatory residents.

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.

During visit, LPAs along with consulting manager toured the physical plant, reviewed files and conducted interviews.
(- continued in LIC 9099 C -)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210910144641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/15/2021

NARRATIVE

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The investigation consisted of the following: physical plant was toured to obtain census and determine overall conditions of the home. LPAs attempted to interview Resident #1 to Resident #3 but residents were non-verbal. Four (4) residents were observed; no immediate health and safety threats were identified.

LPAs also interviewed Staff #1, #2, #3; three hospice care nurses; and one home care aid. Resident#1, #2 and #3 are on hospice and need 24-hours, 7 days week assistance. The home care aid revealed that Resident # 4 has dementia and is receiving home care from 7 am to 7pm daily. The applicant has hired a staff to provide assistance daily from 7 pm to 7 am. Resident#1 - Resident#4’s medication are centrally stored in the facility. The applicant's staff hold the lock key. Vanessa provided LPA Tao the copies of the rental agreements.

Perishable and nonperishable foods, and operational utilities were observed. No immediate health and safety concerns were observed during the visits.

Based upon the investigation, the preponderance of evidence standard has been met. The allegation of Unlicensed care being provided is Substantiated based on resident #4 requiring and receiving care & supervision.

As a result of substantiated Unlicensed Care, the following deficiency is cited per Health & Safety Code 1503.5.

A Notice of Operation in Violation (NOV) of Law and Appeal Rights were given to Kenneth Yu and Vanessa Ricchiazzi.

Plan of correction (POC) cleared on today's 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.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC9099 (FAS) - (06/04)

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