<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603494
Report Date: 01/18/2022
Date Signed: 01/18/2022 04:47:00 PM

Document Has Been Signed on 01/18/2022 04:47 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 & WELLNESS - HOLLYFACILITY NUMBER:
198603494
ADMINISTRATOR:YU, DAVIDFACILITY TYPE:
740
ADDRESS:1740 HOLLY AVETELEPHONE:
(626) 315-2561
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 0DATE:
01/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:David Yu, applicant,
Kenneth Yu, assistant,
Vanessa Ricchiazzi, consulting manager		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 announced pre-licensing inspection. This is an initial application applying for Residential Care for Elderly to serve residents for age 60 and above. LPA met with David Yu, applicant, Kenneth Yu, assistant, and Vanessa Ricchiazzi, consulting manager. The requested capacity is 6. Resident census is zero (0). The licensee is Assisted Living & Wellness, Inc. Fire clearance was approved on 11/30/2021. Facility applied for a Dementia Care program.

Fire clearance:
Fire clearance was granted on 11/30/21 for five (5) non-ambulatory and one (1) bedridden. Fire clearance has a note stating Room #1 granted clearance for bedridden. Dementia care plan is in place. Auditory alarm devices are installed at the entrance door and exit backyard doors.

Structure:
The property is a single-family residence located in a neighborhood, consisting of six (6) bedrooms, three (3) full bathrooms, 1 quarter bathroom (only has a toilet and a sink), kitchen, dining room, sun room, den, nook, laundry room, office, and living room with a TV. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris.

Signal system and Garage:
Facility does not have a signal system.
Garage is not accessible to residents.

(-continued in LIC 809-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: ASSISTED LIVING & WELLNESS - HOLLY
FACILITY NUMBER: 198603494
VISIT DATE: 01/18/2022
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
26
27
28
29
30
31
32
Bedrooms for Residents:
Bedrooms have night stand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Bedroom #1 is approved for bedridden resident, Room #2 to #6 are for non-ambulatory residents.

Bathrooms:
Toilet, wash basin, bathtub/shower in bathrooms are operable. Bathrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower.

Linens & Hygiene Supplies:
Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash cloths and towels are observed.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Medications, First-Aid Kit & Book:
Medication cabinet is installed with a lock and inaccessible to residents.
First aid kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze.
First Aid manual from American red cross was available for staff use and inaccessible to residents.

Smoke Detectors:
Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom.

(- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ASSISTED LIVING & WELLNESS - HOLLY
FACILITY NUMBER: 198603494
VISIT DATE: 01/18/2022
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
26
27
28
29
30
31
32
Appliances:
Stove burners are working. There is one refrigerator located in the kitchen and measured of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted near the entrance. Exit Plan are available for review.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Residents & Staff Files:
Locked cabinets for records of staff and residents are installed and available. Residents file are not observed since no resident residing at the facility. Applicant will not handle cash resources for residents.
Menu and phone:
Menus are available for review.
Free landline telephone is available for residents’ use and it is operable.

(-continued in LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ASSISTED LIVING & WELLNESS - HOLLY
FACILITY NUMBER: 198603494
VISIT DATE: 01/18/2022
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
26
27
28
29
30
31
32
Fire extinguishers:
Fire extinguisher is available in the facility. It is mounted on wall located at laundry room. It is fully charged and last service is on 11/18/2021.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials for the residents’ use and commensurate with the plan of operation.

Pool:
No bodies of water located at the facility.

During today's visit, LPA observed the following corrections are needed.


1. Water temperature was tested at 150.5 degrees Fahrenheit.
2. Oven, washer and dryer are not secured and installed.
3. Top cabinet at the laundry room for storing detergents and toxins solutions need to be inaccessible to residents. The cabinet needs to install a key lock.
4. The patio from the master room (Resident room #6) had an uneven ground near the sliding door.

Due date of the corrections is 1/26/2022.

Exit interview:

Component III was conducted during this visit.

A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4