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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603483
Report Date: 10/21/2024
Date Signed: 10/21/2024 04:25:37 PM

Document Has Been Signed on 10/21/2024 04:25 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/
DIRECTOR:		YU, DAVIDFACILITY TYPE:
740
ADDRESS:220 W. NAOMI AVETELEPHONE:
(626) 315-2561
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 6DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jennifer Sandoval, administrator assistant/ House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Jennifer Sandoval, administrator assistant/ House Manager and the purpose of the visit was explained. The facility was licensed to serve five (5) bedridden and one (1) ambulatory residents, ages 60 and above. The facility had an approved Hospice Waiver for six (6) residents. No resident was bedridden. Three (3) residents were on hospice. Annual fees were current. Administrator certificate was current until 11/30/24.
This annual visit consisted of using CARE tools, physical plant, review of food supply/medications/ resident files/ staff files and residents/staff interviews. The facility is located in a residential area, a single-story home consisted of six (6) bedrooms, three (3) bathrooms, kitchen, dining room, and living room with a TV. Kitchen was clean and has maintained the required two (2) days perishable and seven (7) days non-perishable. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Facility maintains a comfortable temperature of 74 degrees Fahrenheit for residents. Residents' bedrooms settings were in compliance. Adequate linen and personal hygiene supply were observed. Dual combos device (smoke detector combined with carbon monoxide detector) were operable and hard wired. Fire extinguishers were fully charged Auditory devices were operable. The last Fire/ Emergency Drill was conducted on 8/16/24. Outdoor activity area had a shaded patio with ample seating. Medication /resident files/staff files were centrally stored in a locked storage room and inaccessible to residents.

Deficiency was cited per California Code of Regulations, Title 22.

An exit interview was conducted and this report was provided to Jennifer.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 04:25 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/21/2024 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Water temperature ..(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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Hot water temperature is in a range of 128.5 to 129.5 degrees Fahrenheit which was NOT within Title 22 Regulation guidelines.
Deficient Practice Statement
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Based on observation and file review, it poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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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 Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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