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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603648
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:37:22 PM

Document Has Been Signed on 05/16/2023 03:37 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:OMEO ARCADIA LIVINGFACILITY NUMBER:
198603648
ADMINISTRATOR:ZHANG, JINGFANGFACILITY TYPE:
740
ADDRESS:601 SUNSET BLVDTELEPHONE:
(323) 422-8030
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 99CENSUS: 0DATE:
05/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Applicant Jennifer Zhang TIME COMPLETED:
09:35 AM
NARRATIVE
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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 to observe corrections.

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

The following Corrections were observed:

- Repairs to Room #301 have been finished and obstructions in the hallways observed.
- Room #301 has been furnished with required bed, bedding supplies, chair, and night stand with lamp

Physical Plant is now cleared.

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: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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