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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603483
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:34:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/28/2024 and conducted by Evaluator Tyler Reyes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241028114639
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: 7DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Mirna Cuevas Caregiver TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility operating out of capacity.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Tyler Reyes and Luis Deleon conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPAs met with Mirna Cuevas Caregiver and explanined the reason for the visit.

The investigation consisted of the following:
During the visit, LPAs interviewed Staff #1( S1- S5) and Residents (R1-R4) . LPAs requested copies of the resident roster, staff roster, Physician’s Reports for R1-R7, Home Helath for R1, and Hospice Care Plan for R2.


--Continued LIC 9099-C--
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20241028114639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ASSISTED LIVING & WELLNESS - NAOMI
FACILITY NUMBER: 198603483
VISIT DATE: 12/03/2024
NARRATIVE
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The investigation revealed the following: In regards to the allegation that Facility operating out of capacity. (5) of (5) staff confirmed the allegation. Staff confirmed that Assisted Living and Wellness - Naomi is operating over capacity with (7) residents despite being licensed for (6) residents. (4) of (4) residents confirmed the allegation. Resident indicated the location of their bedroom at Assisted Living and Wellness -Naomi. LPAs observed with S1 that R1 - R7 are receding under Assisted Living and Wellness -Naomi. The facility is licensed for an age range 60 and over. Approved for one (1) ambulatory and five (5) bedridden in rooms numbers 1,2,3,5, and 6 only. Hospice waiver approved for six (6). Facility is operating beyond the conditions and limitations specified on the license. Facility is providing care and supervision for (7) residents despite being licensed and approved for (6) residents.


Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the 9099-D. Exit interview held and a copy of the report along with appeal rights were provided.


Immediate Civil Penalty in the amount of $500 was assessed during today's visit. Civil penalties will continue at $100.00 per day until deficiency is corrected.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20241028114639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87204(a)
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87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement has not been met by evidence of:
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Licensee will notify the local fire department of the over capacity and assist with resident relocation. Licensee will submit proof of contact with fire department and details of the residents relocation will be provided to LPA. Licnesee agrees to abiding to capciity limit.
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Based on observations LPA observed a total of (7) residents. LPAs observed with staff #1 (S1) that Resident #1 (R1 - R7) are receding under Assisted Living and Wellness -Naomi. The facility is licensed for an age range 60 and over. Approved for one (1) ambulatory and five (5) bedridden in rooms numbers 1,2,3,5, and 6 only. Hospice waiver approved for six (6). Facility is operating beyond the conditions and limitations specified on the license. Facility is providing care and supervision for (7) residents despite being licensed and approved for (6) residents. This poses an immediate health, safety or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/28/2024 and conducted by Evaluator Tyler Reyes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241028114639

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: 7DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Mirna Cuevas Caregiver TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff does not rotate and reposition residents resulting in pressure sore(s).
Staff not providing medical attention to resident.
Facility has mold.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Tyler Reyes and Luis Deleon conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPAs met with Mirna Cuevas Caregiver and explanined the reason for the visit.

The investigation consisted of the following:
During the visit, LPAs interviewed Staff #1( S1- S5) and Residents (R1-R4) . LPAs requested copies of the resident roster, staff roster, Physician’s Reports for R1-R7, Home Helath for R1, and Hospice Care Plan for R2.


--Continued LIC 9099-C--
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20241028114639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ASSISTED LIVING & WELLNESS - NAOMI
FACILITY NUMBER: 198603483
VISIT DATE: 12/03/2024
NARRATIVE
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The investigation revealed the following: In regards to the allegation that Staff does not rotate and reposition residents resulting in pressure sore(s). (5) of (5) staff denied the allegation. Staff indicated they follow the care plan and orders of the physician. Staff indicated they reposition their resident every 2hrs or as needed by resident.(4) of (4) residents denied the allegation. Resident stated when assistance is needed for repositioning staff is responsive. LPAs observed staff attending to residents needs and the transferring of resident from bedroom to dining room for lunch.

The investigation revealed the following: In regards to the allegation that Staff not providing medical attention to resident. (5) of (5) denied the allegation. Staff indicated that staff are quick to respond to the needs of the resident. Staff stated they were properly trained on ensuring residents receive medical attention. (4) of (4) residents denied the allegation. Residents indicated that staff were pleasant and good about responding to their needs.

The investigation revealed the following: In regards to the allegation that Facility has mold. (5) of (5) staff denied the allegation. Staff stated that despite being an older facility this facility is kept very clean. Staff denied witnessing any mold throughout the facility. (4) of (4) residents denied the allegation. Residents indicated that they have not seen any mold throughout the facility. During a tour of the facility LPAs observed no mold in the bedrooms, closets, restrooms, and kitchen, and kitchen drawers.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.


Exit interview held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5