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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603445
Report Date: 10/28/2021
Date Signed: 10/28/2021 05:01:21 PM

Document Has Been Signed on 10/28/2021 05:01 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:ARCADIAN, THEFACILITY NUMBER:
198603445
ADMINISTRATOR:STARNES, CINDIFACILITY TYPE:
740
ADDRESS:753 W DUARTE ROADTELEPHONE:
(626) 445-7981
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 120CENSUS: 70DATE:
10/28/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Amber Branconier, LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Licensee, Amber Branconier who assisted with the visit. The facility has a capacity of 120 residents. It is licensed to serve elderly residents age 60 and above, approved for 120 non ambulatory residents of which 21 may be bedridden. The facility has five (5) Hospice Waiver for on file. Annual licensing fees are current. LPA discussed the purpose of today's visit.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is a two-story building with 60 resident rooms. Facility consists of Lobby/Reception Area, office, medication room, Activity Room, TV/Entertainment Room, Beauty Shop, Employee Room with lockers and time clock, laundry room, kitchen, and dining room. Medications were centrally stored. Medications room was locked and inaccessible to residents in care. Seven residents’ medication records were reviewed. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. LPA inspected Resident room # 102A, 103B, 105B, 117A, 119A, 122A, 215A, 225B, and 230A. Resident bedrooms had furniture, lighting fixtures and personal storage space as required, mattress pads observed on all beds, the required amount of linen also observed. 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 115.5 to 118.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. Signal systems were tested in resident rooms. The system was operable and staff responded to resident rooms within five minutes. Last Fire Drill was conducted March 16, 2021.

Administrator certificate is current with expiration date on 2/13/2022.

(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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: ARCADIAN, THE
FACILITY NUMBER: 198603445
VISIT DATE: 10/28/2021
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Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean, plates, cups, glasses and utensils for the current census. A comfortable temperature of 74 degrees Fahrenheit maintained throughout the entire facility.

Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. Audio devices were operable. First aid kits were fully stocked with manual. All mandated documents and signages are posted in common areas.



Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed.

Deficiency was cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Licensee, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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Document Has Been Signed on 10/28/2021 05:01 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/28/2021 at 04:33 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARCADIAN, THE
FACILITY NUMBER: 198603445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation, the bathtubs in Resident room # 105 and #119 have a 4” crack. This poses a potential health and safety risk to residents.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee agreed to fix the bath tub cracks by due date on Friday 11/5/21. Pictures of the fixed bathtubs will be submitted to Licensing as POC
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
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