198603648-8-13-2024-28-AS-BTAO-D853DM-20240813180942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603648
Report Date: 08/13/2024
Date Signed: 08/13/2024 06:10:28 PM

Document Has Been Signed on 08/13/2024 06:10 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 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: 84	DATE:	08/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Jennifer (Jingfang) Zhang, administrator		TIME 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 Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Jennifer (Jingfang) Zhang, administrator and the purpose of the visit was discussed. The facility is licensed to serve for a capacity of 200 residents including 175 non-ambulatory and 25 bedridden residents, ages 60 and above. The facility is approved for twenty-three (23) hospice residents and has an approved Dementia Care Plan. Annual licensing fees are current. For today’s inspection visit, the CARE tool was used, a physical plant was conducted, food supply was reviewed, staff/residents were interviewed, residents’ facility records were reviewed, and medications were reviewed. Since no staff file records were maintained in the facility during the visit, no staff file was reviewed and this deficiency would be cited in LIC 809D. The facility is located in a residential neighborhood, consists of three floors/levels 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 fireplace in the activity room with a metal screen cover and is inaccessible to residents. There is a large, covered patio area, with a fishpond on the premises. There is an underground floor for staff and visitor parking. Residents’ rooms were well furnished and in compliance. The bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 110.2 - 118.8 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. The signal system was tested randomly in different resident's room on each level and they were operable. (- continued on LIC 809C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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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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: 08/13/2024

NARRATIVE

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Staff arrived at residents' rooms to respond the calls in a range of 5 to 10 minutes. The facility phones for residents’ use were located at the front desk and operable.

Facility had central air and heating accommodations to maintain a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable at the memory care unit at the lower level. Interior and exterior space was available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods were observed. The last Fire/Emergency Drill was conducted on 6/19/24. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers’ last service was on 12/28/22 and in compliance. Outside fishpond area with self-latching fenced gate was observed. The outdoor activity area has a shaded patio with ample seating.

Medications were centrally stored and locked in the nurse's office. Resident records were stored in a locked cabinet and inaccessible to residents.

Deficiencies were observed and cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/13/2024 06:10 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care (h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: A two-day (48 hours) doses of Resident#7’s Rx Carvedilol, was transferred to another container from its original bubble package for the period of 8/14/24 to 8/15/24.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Administrator, Jennifer agreed to provide (1) additional medication administration assistance training to all staff and provide proof to the department; (2) review Title 22, Section 87465 and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date

Type A

Section Cited

CCR

87309(a)

Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Two bottles of laundry detergents were left in an unlocked laundry room, which the laundry room door was open and the laundry detergents were accessible to residents.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Licensee agreed to lock the Disinfectants, cleaning solutions, poisons items and provide training to staff to ensure those items were not accessible to residents by the POC date

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	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/13/2024 06:10 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: No staff file, nor administrator’s facility files were accessible, nor available for Licensing to review during the inspections. No staff files were located at the facility.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Licensee agreed to maintain personnel records and accessible for Licensing for review and inspection 24/7.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Air condition in the kitchen is not working; room 317’s screen windows had holes and the window was unable to slide open; a few pieces of old furniture and a janitor cleaning cart were blocking the stairways on the second and third floor.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Administrator agreed to repair kitchen air condition, patch the Room 317 screen window and fix the window, clear the passageway and stairway on the second and third floor by POC due date.

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	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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