Assisted Living & Wellness - Naomi B

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. 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 for the period 05/01/26 through 05/13/26. Appeals Rights discussed and a copy to Kenny Yu given during visit.the state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with caregiver Kristina Brown whom assisted with the facility tour and the Licensee Kenny Yu was informed and arrived shortly after. LVNs Carrion and Grancich also arrived to assist with staff and resident files. The facility is licensed to serve four (4) non ambulatory, of which two (2) may be bedridden in Room#1, ages 60 years old and above. The facility has approved Hospice Waiver for four (4) residents. Currently, there are two (2) residents in hospice placement Administrator certificate is current and the expiration date is 07/22/2026. During the visit, LPA completed the Care tool, interviewed staff/residents, reviewed staff/residents' records, toured the facility, reviewed food supply and medications. The facility is a single-family residence located in a neighborhood, consisting of two (2) bedrooms, one (1) bathroom, kitchen, dining area, laundry area, and sitting area; combined. Passageways, walkways, entrance and patio are free from obstructions. Rooms are furnished with appropriate furniture for residents’ comfort and in compliance. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. The outdoor activity area had a shaded patio with ample seating. Facility liability expires10/22/2026. Hot water temperature was measured in a range of 105.9 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Sufficient supply of perishable and nonperishable foods was observed. Knives, tools, and sharp items were inaccessible to residents. Smoke and carbon monoxide detectors were dual/hardwired and operable. Fire extinguishers were fully charged. Medication was centrally stored in a locked cabinet in the living room and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. CONTINUED ON 809C............... No deficiencies were observed and cited according to the California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed and provided to LVN Margaret Grancich. Administrator will email LPA updated Disaster Plan 610E with updated review.the state’s words, verbatim · CDSS document, May 5, 2026

Allegation investigated: Licensee did not obtain the required city permits for the Accessory Dwelling Unit (ADU)

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 Vaid and staff#2 conducted a physical plant tour and observed the residents health and safety . LPA requested, obtained and reviewed the staff and resident rosters. On 09/08/2025, LPA Vaid conducted the initial visit. LPA Vaid was met by Tatiana Equida who allowed entry and notified the administrator. LPA Vaid spoke with Administrator Jenifer Sandoval and purpose of the visit was discussed regarding the above-mentioned allegations. Jenifer Sandoval was not available due to personal issues. Licensee Kenny Yu met with LPA Vaid and the complaints were discussed. LPA requested, obtained and reviewed the staff and resident rosters. CONTINUED ON 9099C......... Substantiated Regarding the allegation: Licensee did not obtain the required city permits for the Accessory Dwelling Unit (ADU). It is alleged that the licensee did not obtain the required city permits for the ADU. 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 04/18/2023. Interviews with one of one resident 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 Unit B 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 cencus is two residents. Four of four staff deny this allegation. The facility has the allowable capacity of four (4) residents allowed to reside in the facility. According to records reviewed, the 4-bed facility has one (1) resident is currently residing at the facility. One of one resident could not corroborate the allegation; residents do not know the capacity limitations and management operations. R1 has not seen other residents in the facility. 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-20250902115045

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 been not 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: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun conducted an unannounced annual subsequent inspection visit. LPA met with facility Administrator, Jennifer Sandoval. The purpose of today's visit was discussed. The facility has a capacity of 4 residents. It is licensed to serve elderly residents aged 60 and above, approved for 4 non-ambulatory residents of which 1 may be bedridden. The facility has two (2) Hospice Waivers on file. Annual licensing fees are current. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 2) PHYSICAL PLANT The Passageway in the front of facility may present an obstruction, due to storage of RV camper parked in front of facility. Facility Administrator was advised to contact the fire department and get clearance to continue to have the camper parking in that space. 4. Staffing: The facility has sufficient staffing, and the night supervision staff have current CPR/first aid certification. (continue on 809C) (continued from 809) 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Some staff did not have required ongoing training. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/Appraisal Needs & Services Plan. One resident does not have admission agreement. Resident was displaced due to fires in January 2025 and responsible party has not returned the admission agreement. 7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster are not posted. entry. Visiting hours are included in admission agreement. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and did not have sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. Staff purchased perishable 2-day food for facility during visit but not 7 day non-perishable 10. Incidental Medical and Dental: Some medication is centrally stored and locked in the medication cabinet in the kitchen. two (2) centrally stored resident medications were reviewed, which contained 30-day supply of medications. One resident did not have a label on PRN bottle. Some medications were accessible to residents as they were in refrigerator and in resident’s room unlocked. Disaster preparedness: The last fire drill was conducted on 03/05/25. The facility has an Emergency Disaster Plan (LIC610E) that needs to be updated. The facility has two (2) alternative temporary shelter locations. 12. Resident with Special Health Needs: 0 residents are receiving home health services. No resident is currently on postural support. Individual Service Plans and Appraisals are on file. Deficiencies observed during today’s visit. Technical Advisories provided. An exit interview was held. A copy of this report, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lopez conducted an unannounced annual inspection visit. LPA met with Jennifer Sandoval administrator and discussed the purpose of the visit. The facility is licensed to serve four (4) non ambulatory, of which two (2) may be bedridden in Room#1, ages 60 years old and above.The facility has approved Hospice Waiver for four (4) residents. Currently, there are two (2) residents on hospice in placement. Administrator certificate is current and the expiration date is 07/22/2025 During the visit, LPA completed the physical plant domain, and toured the facility, The facility is a single-family residence located in a neighborhood, consists of two (2) bedrooms, one (1) bathroom, kitchen, dining area, laundry area, and sitting area. Passageways, walkways, entrance and patio are free from obstructions. Rooms are furnished with appropriate furniture for residents’ comfort and in compliance. The bathrooms are furnished with grab bars and nonskid surfaces. Hot water temperature was measured between 127.0 and 127.2 degrees Fahrenheit which is not within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. Knives, tools, sharp items were inaccessible to residents. Smoke and carbon monoxide detectors were dual/hardwired and operable. Fire extinguisher was fully charged. Deficiencies observed and cited on 809D. Due to time constraints, LPA will return another day to complete inspection. Exit interview conducted and copy of report, 809D and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Kenny Yu, administrator, and Staff#2 (S2) facility manager, who assisted with visit. The facility is licensed to serve four (4) non ambulatory, of which two (2) may be bedridden in Room#1, ages 60 years old and above. The facility has approved Hospice Waiver for four (4) residents. Currently, there are two (2) residents on hospice in placement. Administrator certificate is current and the expiration date is 11/30/24. During the visit, LPA completed the Care tool, interviewed staff/residents, reviewed staff/residents' records, toured the facility, reviewed food supply and medications. The facility is a single-family residence located in a neighborhood, consists of two (2) bedrooms, one (1) bathroom, kitchen, dining area, laundry area, and sitting area. Passageways, walkways, entrance and patio are free from obstructions. Rooms are furnished with appropriate furniture for residents’ comfort and in compliance. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. The outdoor activity area had a shaded patio with ample seating. Hot water temperature was measured in a range of 105.9 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. Sufficient supply of perishable and nonperishable foods were observed. Knives, tools, sharp items were inaccessible to residents. Smoke and carbon monoxide detectors were dual/hardwired and operable. Fire extinguishers were fully charged. Medication was centrally stored in a locked cabinet in the living room and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed and provided to Staff#2.the state’s words, verbatim · CDSS document, Apr 18, 2024