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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603494
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:47:16 PM


Document Has Been Signed on 02/20/2024 03:47 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 - HOLLYFACILITY NUMBER:
198603494
ADMINISTRATOR:YU, DAVIDFACILITY TYPE:
740
ADDRESS:1740 HOLLY AVETELEPHONE:
(626) 315-2561
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:6CENSUS: 6DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kenny Yu, administrator
Vanessa Ricchiazzi, consultant
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with administrator Kenneth and consultant Vanessa whose assisted with visit. The facility is licensed to serve six (6) non-ambulatory residents, ages 60 and above, of which one (1) may be bedridden. Bedroom#6 is approved for bedridden. The facility has an approved Hospice Waiver (for six (6) residents) and a Dementia Care program. Administrator certificate is current and the expiration date is 11/24/24. Annual fees are current.

During the visit, the CARE tool was used, staff /residents were interviewed, staff/residents records were reviewed, physical plant was conducted, food supply was reviewed, and medications were reviewed.

The facility is a single-family residence located in a neighborhood, consisting of six (6) bedrooms, three (3) full bathrooms, 1 quarter bathroom (only has a toilet and a sink), kitchen, dining room, sun room, den, nook, laundry room, office, and living room with a TV. No pools and bodies of water on the premises. 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. Hot water temperature was 114.6 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. Auditory alarm devices to monitor exits were operable. Sufficient supply of perishable and nonperishable foods is observed. Smoke and carbon monoxide detectors are dual/hardwired and operable. Fire extinguishers’ last service is 3/23/23 and are fully charged. Medication is centrally stored in a locked cabinet and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed and provided to Administrator.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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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