Assisted Living & Wellness - Holly

Type of visit: Required - 1 Year

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 Ricchiazzithe state’s words, verbatim · CDSS document, Feb 17, 2023

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Jan 28, 2022

Type of visit: Prelicensing

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-) 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 -) 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-) 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.the state’s words, verbatim · CDSS document, Jan 18, 2022

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: David Yu, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Staff training 4. Applicant and Administrator qualifications 5. Grievances, Complaints, Community resources 6. Food service 7. Medication management 8. Application document review and technical assistance: Pre-licensing inspectionthe state’s words, verbatim · CDSS document, Dec 16, 2021