198603648-5-5-2023-28-AS-JVIS-CRJPYS-20230505114424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603648
Report Date: 05/04/2023
Date Signed: 05/05/2023 11:44:28 AM

Document Has Been Signed on 05/05/2023 11:44 AM - 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:	OMEO ARCADIA LIVING		FACILITY NUMBER:	198603648
ADMINISTRATOR:	ZHANG, JINGFANG		FACILITY TYPE:	740
ADDRESS:	601 SUNSET BLVD		TELEPHONE:	(323) 422-8030
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY: 99		CENSUS: 0	DATE:	05/04/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Applicant Jennifer Zhang		TIME COMPLETED:	04:15 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 Analyst (LPA) Jose Villalobos conducted an announced visit with applicant Jennifer Zhang. The purpose of the visit was to conduct the subsequent Pre-Licensing visit. An application was submitted to CCLD on 11/3/2023, for a Change of Ownership of a Residential Care Facility for the Elderly. The requested capacity of 99 residents, (0) ambulatory, (99) non-ambulatory and (0) may be bedridden. Hospice Waiver request was submitted for up to Fifteen (15) residents. The facility is currently operating under Facility #198603374 Structure/Physical Plant: The facility is a large 3 story structure with 90 bedrooms, 86 bathrooms, 1 TV room, an administrative office, a restaurant style kitchen, a laundry room, a janitor storage room, and two elevators. The facility has a gas fire place in the activity room with a metal screen cover and is inaccessible to residents. There is a large, covered patio area, with a fish pond on the premises. There is an underground floor for staff and visitor parking. Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Residents Rooms: Bedrooms #101-107, #110-115 , #121-129, #203-215, #220-228 , and #301-315 were observed. Most bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bedrooms have attached bathrooms, Bedrooms #301 and 302 not furnished. Bathrooms: Bathrooms observed to meet Title 22 requirements. Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There are two (2) cordless phone for residents use. Fire Extinguisher(s) fully charged and up to date Continued on LIC 809-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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: OMEO ARCADIA LIVING	FACILITY NUMBER: 198603648
	VISIT DATE: 05/04/2023

NARRATIVE

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Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates were observed. Knives, cutlery and other sharps inaccessible to residents will be kept in a kitchen inaccessible to residents. Smoke Detectors & Fire Extinguishers: Facility has Fire Panel that notifies Fire Department when set off. LPA observed system last serviced on 4/17/23 and currently working. Smoke detectors and also carbon monoxide detectors observed, throughout resident rooms and common areas. Tested and operational. Appliances: Kitchen stove burners and oven operational. Microwave, washers and dryers are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured and within Title 22 Regulations Medications, First-Aid Kit & Book: Medications central storage location inaccessible to residents was observed. First aid kit inspected and all required items observed. Residents & Staff Files: Facility has a locked areas for resident and staff files. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: Observed and Fenced Fire clearance: Fire clearance was approved on 1/24/23.

Component III:
Component III was conducted with applicant at the time of this visit.

The Physical Plant is not cleared at the time of visit. The following Correction needs to be made prior to clearance:

- Room #301 to have repairs finished and material to be stored not blocking entrance to room.
- Room #301 to be furnished with required bed, bedding supplies, chair, and night stand with lamp

Applicant to Submit proof of corrections to LPA by 5/12/23

An exit interview was conducted and a copy of this report has been furnished to the applicant . Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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