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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603494
Report Date: 01/28/2022
Date Signed: 01/28/2022 10:08:07 AM

Document Has Been Signed on 01/28/2022 10:08 AM - 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:
01/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kenneth Yu, Administrator assistant,
Vanessa Ricchiazzi, consulting manager		TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Tao conducted an announced subsequent pre-licensing inspection. The initial was conducted on 1/18/22. The facility is applying for Residential Care for Elderly to serve residents for age 60 and above. LPA met with Kenneth Yu, administrator assistant and Vanessa Ricchiazzi, consulting manager.

During today's visit, LPA toured the facility and observed:
1. Water temperature was tested at 112.5 degrees Fahrenheit.
2. Oven, washer and dryer are secured and installed.
3. Top cabinet at the laundry room for storing detergents and toxins solutions are inaccessible to residents. The cabinets are installed a key lock.
4. The uneven ground of the patio of Resident room #6 near the sliding door at is paved and leveled.

No issues for correction are observed.

An Exit interview was completed with Kenneth Yu and Vanessa Ricchiazzi. A copy of this licensing report LIC 809 has been furnished to applicant. Applicant is advised to contact Centralized Application Bureau regarding the status of the application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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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