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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603494
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:22:00 PM

Document Has Been Signed on 02/17/2023 01:22 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
GREATER LA AC/SC, 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: 6DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Mirna Cuevas/David Yu TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Mirna Cuevas and discussed the purpose of today's visit. Kenny Yu (Operations Manager) arrived at approximately 8:25 A.M. David Yu (Administrator) arrived at approximately 8:50 A.M.. Vanessa Ricchiazzi (Administrative Consultant) and Jennifer Sandoval (Wellness Director) arrived at approximately 9:20 A.M..

This home consists of (6) private bedrooms, (4) bathrooms, kitchen, dining area, laundry room, office, sun room and detached garage. This facility is licensed for (6) non-ambulatory beds which (6) may be under hospice care and (1) may be bedridden. There are currently (5) residents under hospice care (R-2 through R-5). There is (1) bedridden resident (R-6).

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Incontinence care supplies observed. Each Resident has their own incontinence supplies stored inside their bedrooms.
  • Bathrooms have hand soap, paper towels, grab bars and non-skit mats. Bathrooms have hand washing signs posted.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Medication reviewed for Resident #1 through Resident #6 (R-1 through R-6).
  • Staff responsible for direct care and supervision were wearing masks.
  • Residents were socially distanced according to local public health guidelines.


Exit interview conducted, a copy of this report and Appeal Rights were provided to David Yu and Vanessa Ricchiazzi
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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