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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801730
Report Date: 03/11/2022
Date Signed: 03/11/2022 05:08:27 PM

Document Has Been Signed on 03/11/2022 05:08 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FINEST LIVING AT ARCADEFACILITY NUMBER:
565801730
ADMINISTRATOR:GARNER J. CRUZFACILITY TYPE:
740
ADDRESS:350 SOUTH ARCADE DRIVETELEPHONE:
(805) 628-9181
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 6DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Adelaida CruzTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with Licensee/Representative Adelaida Cruz.

LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Licensee/Representative. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed a sufficient supply of perishable food. LPA observed hot water temperature at 109 degrees F. PPE supplies were observed. LPA observed the fire extinguisher fully charged. The smoke detectors and carbon monoxide detectors were tested and operable. LPA observed appropriate lighting in residents rooms. Medications are stored in a locked medication closet. Outdoor area toured- passageways are free of obstruction. LPA reviewed resident records.

During facility tour at 11:05 am with staff Remwel Patawaran LPA observed scissors in an unlocked drawer in the kitchen accessible to residents.

During facility tour at 11:08 am with staff Patawaran LPA did not observe a sufficient supply of nonperishable food as the facility did not have any nonperishable fruit.

During facility tour at 11:11 am with staff Patawaran LPA observed facial cleanser, mouthwash, shampoo, conditioner, body wash and toothpaste in staff bathroom accessible to residents.

During facility tour at 11:17 am with staff Patawaran LPA observed a razor, deodorant, body cream, calmoseptine ointment, vitamins a & d ointment and perineal wash in resident bathroom accessible to residents.

Continued on 809C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FINEST LIVING AT ARCADE
FACILITY NUMBER: 565801730
VISIT DATE: 03/11/2022
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/11/2022 05:08 PM - It Cannot Be Edited


Created By: Joann Rosales On 03/11/2022 at 01:01 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINEST LIVING AT ARCADE
FACILITY NUMBER: 565801730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as LPA did not observe any nonperishable fruit which poses health and personal rights risk to persons in care.
POC Due Date: 03/15/2022
Plan of Correction
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Licensee/Representative stated that they will provide documentation of a one week supply of nonperishable fruit to CCL by 3/15/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/11/2022 05:08 PM - It Cannot Be Edited


Created By: Joann Rosales On 03/11/2022 at 01:01 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINEST LIVING AT ARCADE
FACILITY NUMBER: 565801730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above as scissors were observed accessible to residents which poses an immediate safety risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff placed scissors in an inaccessible location during the facility visit. Licensee/Representative stated that they will conduct staff training regarding regulation 87705(f)(1) and will provide documentation to CCL by 3/21/22.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above as toxic items were accessible to residents which poses an immediate health risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff placed toxic items in an inaccessible location during facility visit. Licensee/Representative stated that they will conduct staff training regarding regulation 87705(f)(2) and will provide documentation to CCL by 3/21/22.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
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