Assisted Living & Wellness - Naomi

Type of visit: POC

LPA Sanjay Vaid conducted an unannounced POC visit to ascertain that the deficiencies cited during 04/30/26 complaint visit have been corrected. LPA met with Kenny Yu, Licensee. 87305(b) Alterations to Existing Building or New Facilities (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement has not been met as evidenced by: The licensee did not furnish the department with a final inspection report, city permits for the occupancy class code. On today’s POC Visit – LPA was or was not provided with final inspection report, city permits for the occupancy class code regarding the construction to the physical plant. POC not cleared on today’s visit. Civil Penalties issued on today’s visit in the amount of $1300.00 for the period 05/01/26 through 05/13/26. Appeals Rights discussed and a copy to Kenny Yu, Licensee given during visit.the state’s words, verbatim · CDSS document, May 14, 2026

Allegation investigated: The licensee did not obtain proper city clearances

Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to the facility and delivered complaint findings to the facility. LPA Vaid was met by Staff #2(S2), Licensee was notified and arrived soon after. LPA requested, obtained and reviewed the staff and resident rosters. LPA Vaid and staff#2 conducted a physical plant tour and observed the residents Health and Safety with double doors linking the two facilities being used by the staff to facilitate residents in both facilities, double -doors may allow visitors to access both facilities. On 09/08/2025, LPA Vaid conducted the initial visit. LPA Vaid was met by Caregiver, Tatiana Equida, who allowed LPA Vaid entry into the facility and notified the administrator of LPA presence. LPA Vaid spoke with Administrator Jenifer Sandoval and purpose of the visit was discussed regarding the above-mentioned allegations. Administrator Jenifer Sandoval was not available due to personal issues. Licensee Kenny Yu met with LPA Vaid and the complaint allegations were discussed. LPA requested, obtained and reviewed the staff and resident rosters. CONTINUED ON 9099C Substantiated Regarding the allegation: The licensee did not obtain proper city clearances. It is alleged that the Licensee is operating a 6-bed facility adjacent and accessible to a 4-bed facility via double doors, which links the two facilities. It is also alleged that the licensee does not have the proper occupancy code clearance, and did not obtain the proper city clearances to operate a ten-bed facility. Interviews with Licensee revealed the purpose of the double doors is to facilitate staff with residents’ care. Interviews with four of four staff denied this allegation. Staff stated the 6-bed and 4-bed facilities were approved for operations by Community Care Licensing. The license to operate a Residential Care Facility for Elderly was issued on 10/08/2021. Interviews with six of six residents revealed that residents could not corroborate the allegation; as the facility residents are not knowledgeable with the facility operations. According to records reviewed during the investigation, the City of Arcadia, Planning and Zoning, Development Services Department, Codes Services Division issued Notice of Violation and Notice to Abate a Public Nuisance to the facility dated 05/29/25, 06/12/25, 07/17/25, 07/31/25. The notices indicate the violation address and state that the location is in violation for the following Arcadia Municipal Code Section(s) and Corrective Action. • AMC 9402.6B, - Any unsafe building or structure as defined by Section 116 of the California Building Code, as adopted by Article VIII of the Arcadia Municipal Code • AMC9402.6D, - A building or structure or part thereof which was constructed, or partially constructed, without complying with applicable provisions of the Arcadia Municipal Code or other law. • 9402.6P.1 - Buildings which are abandoned, boarded up without City direction, partially destroyed, or partially constructed or uncompleted building after building permits have expired. • AMC 9402.6.F - Any partially constructed building or structure, together with material and equipment used for construction, which is not completed within a reasonable time, or upon which there is a cessation of work for more than sixty (60) days • AMC 9402.6.E - Any building or structure or portion thereof which cannot be lawfully used in its existing location and condition for any purpose for which it is designed. • CBC 105.1 Permits Required The violation address is 220 W Naomi Ave, Arcadia CA 91007-6911. The facility has not corrected the violations which were due within a fifteen-day (15-day) time frame. Per the City of Arcadia, Planning and Zoning, Development Services Department, Codes Services Division, the violations and violation due dates were provided to the Licensee and to date, proof of corrections have not been received. CONTINUED ON 9099C The Corrective Action items listed below have not been corrected: • Contact Building & Safety Division to remove or acquire permits for the unpermitted structure(s). • Correct substandard condition of property • Contact the Building & Safety Division to renew or cancel your permit; if you are canceling your permit, properly remove all construction material and equipment from the property. • Contact the Building & Safety Division to acquire proper permits • Renew all expired building permits • Pass all final inspections • Obtain proper permits for change of occupancy The licensee did not furnish the department with a final inspection report, city permits for the occupancy class code, therefore, an updated fire safety inspection will be requested with the City of Arcadia Fire Department to ensure the residents health and safety. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Exit interview was conducted. Copy of LIC 9099, 9099C, 9099D and appeals were provided to licensee. Regarding the allegation: The facility is operating beyond the limits of the license. It is alleged that the licensee is operating beyond the limits of the license by allowing the facility to house more residents than the capacity allows. Today's census is four (4) residents. Interviews with licensee revealed the allowable capacity of six (6) residents is always maintained. Interviews with four of four staff deny this allegation and revealed that staff reported giving assistance to six (6) residents. Interviews with six of six residents could not corroborate the allegation; the residents do not know the facility capacity limitations and management operations. On 10/08/2021, Community Care Licensing issued a license to operate a Residential Care Facility for Elderly with a capacity of six (6) residents residing in the facility. Additionally, a fire clearance was granted on 08/04/2021 and the facility is approved to retain one (1) ambulatory and five (5) bedridden in room numbers 1, 2, 3, 5 and 6 only. According to LPAs observations and records reviewed, the facility is retaining six (6) residents and is not operating beyond the limits of the license. Based on records review and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and copy of LIC 9099 was provided to licensee.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 28-AS-20250902121024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(b) · Plan of correction due date: Apr 30, 2026

87305 Alterations to Existing Building or New Facilities (b)The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement has not been met with evidence: The licensee did not furnish the department with a final inspection report, city permits for the occupancy class code, therefore, an updated fire safety inspection will be requested with the City of Arcadia Fire Department to ensure the residents health and safety.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Licensee will submit proof of corrections and final City of Arcadia inspection permits to the Department by 04/30/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met Jennifer Sandoval, administrator and the purpose of the visit was explained. The facility is licensed to serve residents age 60 and over. Approved for one (1) ambulatory and five (5) bedridden in rooms 1,2,3,5 and 6 only. Hospice waiver approved for six (6).No residents were bedridden. Three (3) residents were in hospice. Annual visit was conducted using the CARE tools, physical plant, review of food supply/medications/ resident files/ staff files and residents/staff interviews. The facility is in a residential area, a single-story home consisting of six (6) bedrooms, three (3) bathrooms, kitchen, dining room, and living room with a TV. Kitchen was clean and maintain the required two (2) days perishable and seven (7) days non-perishable. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Facility maintains a comfortable temperature of 74 degrees Fahrenheit for residents. Residents' bedrooms furniture in compliance, bed, chair, lamp, dresser. Adequate linen and personal hygiene supply were observed. Dual devices (smoke detector combined with carbon monoxide detectors) were operable and hard wired. Fire extinguishers were fully charged Auditory devices were operable. The last Fire/ Emergency Drill was conducted in October 2025. Outdoor activity area had a shaded patio with ample seating. Medication /resident files/staff files were centrally stored in a locked storage room and inaccessible to residents. Administrator certificate was renewed and is pending. No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted, and this report was provided to Jennifer Sandoval.the state’s words, verbatim · CDSS document, Nov 4, 2025

Allegation investigated: Facility operating out of capacity.

Licensing Program Analysts (LPAs) Tyler Reyes and Luis Deleon conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPAs met with Mirna Cuevas Caregiver and explanined the reason for the visit. The investigation consisted of the following: During the visit, LPAs interviewed Staff #1( S1- S5) and Residents (R1-R4) . LPAs requested copies of the resident roster, staff roster, Physician’s Reports for R1-R7, Home Helath for R1, and Hospice Care Plan for R2. --Continued LIC 9099-C-- Substantiated The investigation revealed the following: In regards to the allegation that Facility operating out of capacity. (5) of (5) staff confirmed the allegation. Staff confirmed that Assisted Living and Wellness - Naomi is operating over capacity with (7) residents despite being licensed for (6) residents. (4) of (4) residents confirmed the allegation. Resident indicated the location of their bedroom at Assisted Living and Wellness -Naomi. LPAs observed with S1 that R1 - R7 are receding under Assisted Living and Wellness -Naomi. The facility is licensed for an age range 60 and over. Approved for one (1) ambulatory and five (5) bedridden in rooms numbers 1,2,3,5, and 6 only. Hospice waiver approved for six (6). Facility is operating beyond the conditions and limitations specified on the license. Facility is providing care and supervision for (7) residents despite being licensed and approved for (6) residents. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the 9099-D. Exit interview held and a copy of the report along with appeal rights were provided. Immediate Civil Penalty in the amount of $500 was assessed during today's visit. Civil penalties will continue at $100.00 per day until deficiency is corrected. The investigation revealed the following: In regards to the allegation that Staff does not rotate and reposition residents resulting in pressure sore(s). (5) of (5) staff denied the allegation. Staff indicated they follow the care plan and orders of the physician. Staff indicated they reposition their resident every 2hrs or as needed by resident.(4) of (4) residents denied the allegation. Resident stated when assistance is needed for repositioning staff is responsive. LPAs observed staff attending to residents needs and the transferring of resident from bedroom to dining room for lunch. The investigation revealed the following: In regards to the allegation that Staff not providing medical attention to resident. (5) of (5) denied the allegation. Staff indicated that staff are quick to respond to the needs of the resident. Staff stated they were properly trained on ensuring residents receive medical attention. (4) of (4) residents denied the allegation. Residents indicated that staff were pleasant and good about responding to their needs. The investigation revealed the following: In regards to the allegation that Facility has mold. (5) of (5) staff denied the allegation. Staff stated that despite being an older facility this facility is kept very clean. Staff denied witnessing any mold throughout the facility. (4) of (4) residents denied the allegation. Residents indicated that they have not seen any mold throughout the facility. During a tour of the facility LPAs observed no mold in the bedrooms, closets, restrooms, and kitchen, and kitchen drawers. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 28-AS-20241028114639

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Dec 4, 2024

87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement has not been met by evidence of: Based on observations LPA observed a total of (7) residents. LPAs observed with staff #1 (S1) that Resident #1 (R1 - R7) are receding under Assisted Living and Wellness -Naomi. The facility is licensed for an age range 60 and over. Approved for one (1) ambulatory and five (5) bedridden in rooms numbers 1,2,3,5, and 6 only. Hospice waiver approved for six (6). Facility is operating beyond the conditions and limitations specified on the license. Facility is providing care and supervision for (7) residents despite being licensed and approved for (6) residents. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: Licensee will notify the local fire department of the over capacity and assist with resident relocation. Licensee will submit proof of contact with fire department and details of the residents relocation will be provided to LPA. Licnesee agrees to abiding to capciity limit.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Reyes and Luis Deleon generated this Case Management - Deficiencies report pertaining to record review of the Staff Roster LIC 500. The purpose of the report was explained to Mirna Cuevas Caregiver and with Vanessa Ricchiazzi over the telephone. LPAs observed upon record review of the staff roster LIC 500 and the LIS Facility Personnel Report Summary that staff #1 (S1 -S7) was not associated to facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the 809D. Exit interview held and a copy of the report along with appeal rights were provided. Immediate Civil Penalty in the amount of $3500 was assessed during today's visit.the state’s words, verbatim · CDSS document, Dec 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 4, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement has not been met by evidence of: Based on record review of the LIC 500 and the LIS Facility Personnel Report Summary that staff #1 (S1 S7) is not cleared to work at facility which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: The Licensee will ensure that all individuals subject to a criminal record review and associated prior to working, residing or volunteering in a licensed facility. Licensee will submit proof of clearance and association for staff #1 (S1 -S7) by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Jennifer Sandoval, administrator assistant/ House Manager and the purpose of the visit was explained. The facility was licensed to serve five (5) bedridden and one (1) ambulatory residents, ages 60 and above. The facility had an approved Hospice Waiver for six (6) residents. No resident was bedridden. Three (3) residents were on hospice. Annual fees were current. Administrator certificate was current until 11/30/24. This annual visit consisted of using CARE tools, physical plant, review of food supply/medications/ resident files/ staff files and residents/staff interviews. The facility is located in a residential area, a single-story home consisted of six (6) bedrooms, three (3) bathrooms, kitchen, dining room, and living room with a TV. Kitchen was clean and has maintained the required two (2) days perishable and seven (7) days non-perishable. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Facility maintains a comfortable temperature of 74 degrees Fahrenheit for residents. Residents' bedrooms settings were in compliance. Adequate linen and personal hygiene supply were observed. Dual combos device (smoke detector combined with carbon monoxide detector) were operable and hard wired. Fire extinguishers were fully charged Auditory devices were operable. The last Fire/ Emergency Drill was conducted on 8/16/24. Outdoor activity area had a shaded patio with ample seating. Medication /resident files/staff files were centrally stored in a locked storage room and inaccessible to residents. Deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted and this report was provided to Jennifer.the state’s words, verbatim · CDSS document, Oct 21, 2024