<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603483
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:35:54 PM

Document Has Been Signed on 12/03/2024 04:35 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
MONTEREY PARK ASC, 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: 7DATE:
12/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:40 PM
MET WITH:Mirna Cuevas CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:00 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 Analysts (LPAs) Reyes and Luis Deleon generated this Case Management - Deficiencies report pertaining to record review of the Staff Roster LIC 500. The purpose of the report was explained to Mirna Cuevas Caregiver and with Vanessa Ricchiazzi over the telephone.

LPAs observed upon record review of the staff roster LIC 500 and the LIS Facility Personnel Report Summary that staff #1 (S1 -S7) was not associated to facility.


Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the 809D. Exit interview held and a copy of the report along with appeal rights were provided.


Immediate Civil Penalty in the amount of $3500 was assessed during today's visit.



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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/03/2024 04:35 PM - It Cannot Be Edited


Created By: Tyler Reyes On 12/03/2024 at 02:17 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: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/04/2024
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement has not been met by evidence of:
1
2
3
4
5
6
7
The Licensee will ensure that all individuals subject to a criminal record review and associated prior to working, residing or volunteering in a licensed facility. Licensee will submit proof of clearance and association for staff #1 (S1 -S7) by POC due date.
8
9
10
11
12
13
14
Based on record review of the LIC 500 and the LIS Facility Personnel Report Summary that staff #1 (S1 S7) is not cleared to work at facility which poses an immediate health risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Tyler Reyes
LICENSING EVALUATOR 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


LIC809 (FAS) - (06/04)
Page: 2 of 2