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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603354
Report Date: 10/21/2024
Date Signed: 10/21/2024 02:32:51 PM

Document Has Been Signed on 10/21/2024 02:32 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 & WELLNESSFACILITY NUMBER:
198603354
ADMINISTRATOR/
DIRECTOR:
YU, DAVIDFACILITY TYPE:
740
ADDRESS:608 WEST PALM DRIVETELEPHONE:
(626) 662-7101
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 6DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Jennifer Sandoval, administrator assistant/ House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Jennifer Sandoval administrator assistant/ House Manager and Kenny Yu, co-manager at the facility and spoke with Consultant, Vanessa Ricchiazzi over the phone. The purpose of the visit was explained. The facility had a capacity of six (6) with approved fire clearance of five (5) non-ambulatory, one (1) bedridden and six (6) hospice waivers. No resident was bedridden. Two residents on hospice. Annual fees were current. Administrator certificate was current with the expiration date on 11/30/24.

This annual visit consisted of using CARE tools, physical plant, review of food supply/medications/ resident files/ staff files and residents/staff interviews. The facility is located in a residential area, a single-story home with six (6) client’s bedrooms, three (3) bathrooms, a living room, a kitchen, a dining room, an activity area, a laundry room and a garage. Residents' bedrooms settings were in compliance. Adequate linen and personal hygiene supply were observed. Kitchen was clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. 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 118.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Facility maintains a comfortable temperature of 74 degrees Fahrenheit for residents. Dual combos device (smoke detector combined with carbon monoxide detector) were operable and hard wired. Fire extinguishers were fully charged Auditory devices were operable. The last Fire/ Emergency Drill was conducted on 6/20/21. Outdoor activity area had a shaded patio with ample seating. Medication /resident files/staff files were centrally stored in a locked storage room and inaccessible to residents.

No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed and provided to Jennifer.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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