198603483-10-20-2022-28-AS-BTAO-CKDUHD-20221020153547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603483
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:36:00 PM

Document Has Been Signed on 10/20/2022 03:36 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 & 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:	10/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	David Yu, administrator Vanessa Consulting Manger		TIME COMPLETED:	02:45 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 unannounced annual inspection visit. LPA met David Yu and Vanessa who assisted with visit. The facility is licensed to serve five (5) bedridden and one (1) ambulatory residents, ages 60 and above. The facility has an approved Hospice Waiver for six (6) residents. Currently, there are four (4) residents in placement. Administrator certificate is current and the expiration date is 7/29/23 . During the visit, the infection control domain tool was used, staff and residents were interviewed, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. LPA observed the facility is a single-family house 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. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke and carbon monoxide detectors are dual/hardwired and operable. Fire extinguishers are fully charged. (-continued in 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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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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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: 10/20/2022

NARRATIVE

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Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet in the hallway and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report was discussed with Administrator. Staff’s signature on this form confirmed receipt of these documents. A copy of LIC 809s report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2022 03:36 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASSISTED LIVING & WELLNESS - NAOMI	FACILITY NUMBER: 198603483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

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	Hot water temperature was in a range of 151.1 degrees Fahrenheit at the kitchen sink and 131.4 degrees Fahrenheit at the bathroom sink which was not within Title 22 Regulation guidelines Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Administrator will ensure the water temperature will remain in a range of 105 - 120 degree Fahrenheit; a water temperature log dated 10/21/22 will provide to Licensing. Licensee will maintain a weekly water temperature log to ensure water temp is within Title 22 Regulation guidelines. Plan of Corrections (POC) must be corrected 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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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