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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603445
Report Date: 04/26/2024
Date Signed: 04/26/2024 04:43:16 PM

Document Has Been Signed on 04/26/2024 04:43 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/
DIRECTOR:		BRYANNA M LUKEFACILITY TYPE:
740
ADDRESS:753 W DUARTE ROADTELEPHONE:
(626) 445-7981
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 120CENSUS: 97DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Amber Branconier, Licensee and
Hardie Lin, Director		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Bonnie Tao and Tyler Reyes conducted an unannounced annual inspection visit. LPA met with facility director, Hardie Lin and Licensee, Amber Branconier. The purpose of today's visit was discussed. 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 on file. Annual licensing fees are current.

During the visit, the CARE tool was used, physical plant/facility tour was conducted, food supply was reviewed, staff/residents’ files were reviewed, and medications were reviewed.

The facility is located at the residential area. The premise 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. Residents' medications are centrally stored and locked in the medication room. LPA Tao inspected twelve (12) residents’ rooms. Resident bedrooms had furniture, lighting fixture and personal storage space as required. Mattress pads were observed on all beds. Bathrooms inspected were clean, operable, and furnished with the required grab bars and non-skid materials in the shower. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. Hot water temperature was in a range of 109.8 to 113.7 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Signal systems were tested in resident rooms and operational. Sufficient supplies of perishable and non-perishable foods were observed. Smoke detectors and carbon monoxide detectors were tested and operational. Fire extinguishers were fully charged. Auditory alarm devices at exits were working.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809D for details. An exit interview was conducted. This report and appeal rights were 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: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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Document Has Been Signed on 04/26/2024 04:43 PM - It Cannot Be Edited


Created By: Bonnie Tao On 04/26/2024 at 04:06 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: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained.

This requirement is not met as evidenced by:
Per review of Resident#1 (R1)'s medication, R1's April 2024 medication record and centrally stored medication destruction records were missing. As review of Resident #6 (R6), resident's medication (Atenolol 50mg) log did not match with the number of pills/ medication administered. Licensee did not document regarding the Rx discrepancy.
Deficient Practice Statement
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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: 04/29/2024
Plan of Correction
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Licensee, Amber, 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.
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: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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