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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603483
Report Date: 09/21/2023
Date Signed: 09/21/2023 05:16:07 PM


Document Has Been Signed on 09/21/2023 05:16 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 - NAOMIFACILITY NUMBER:
198603483
ADMINISTRATOR:YU, DAVIDFACILITY TYPE:
740
ADDRESS:220 W. NAOMI AVETELEPHONE:
(626) 315-2561
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:6CENSUS: 4DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kenny Yu, administratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Kenny Yu, administrator, 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 is one (1) resident on hospice in placement. Administrator certificate is current and the expiration date is 11/30/24.

During the visit, LPA completed the infection control domain tool, interviewed staff and residents, reviewed staff/residents' records, toured the facility, reviewed food supply and medications.



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 residence located in a neighborhood, consisting of six (6) bedrooms, three (3) bathrooms, kitchen, dining room, and living room with a TV. The entrance and side areas are free of hazards and debris. Rooms are furnished with appropriate furniture for residents’ comfort and in compliance. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. 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. The outdoor activity area has a shaded patio with ample seating.

Hot water temperature was measured in a range of 113.2 - 119.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed.

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’ last service was 3/22/23 and were fully charged. (-continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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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: 09/21/2023
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Mandated documents and signages are posted in common areas. Medication is centrally stored in a locked cabinet in the living room 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, Kenny. A copy of LIC 809s report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/21/2023 05:16 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: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
Incidental Medical and Dental Care 87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained.
This requirement is not met as evidenced by:
Upon reviewing medication and medication records for Residents #2, #3 and #4, LPA observed the medication logs were not logged: R#2 -Omeprazoles for 4 days; R#3 - Mirtazapine, Senna, Carvedialol and Queitapine for 3 days; R#4- Amlodipine Besylate, Metoprolol Succinate and Atorvastation for 3 days while medication was administered. LPA did not see any documentation in regard to missing medication log. LPA was unable to determine medication log was updated accordingly.
Deficient Practice Statement
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Based on medication review, 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: 09/22/2023
Plan of Correction
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Administrator agreed to provide (1) additional medication administration assistance training to all staff and provide proof to the department; (2) review Title 22, Section 87465 and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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