197607890-3-12-2024-29-AS-SURA-D3B2AL-20240312171341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607890
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:14:22 PM

Document Has Been Signed on 03/12/2024 05:14 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BE WELL SENIOR LIVING INC.		FACILITY NUMBER:	197607890
ADMINISTRATOR:	RUSLAN MELNIKOV		FACILITY TYPE:	740
ADDRESS:	14739 MORRISON STREET		TELEPHONE:	(818) 205-9313
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	6	CENSUS: 6	DATE:	03/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Elina Root		TIME COMPLETED:	01:34 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at 09:30 a.m. at the facility unannounced to conduct a required annual inspection. LPA Urena was greeted by staff, and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with Administrator Elina Root and explained the reason for the visit.

LPA Urena and the Administrator conducted a tour of the physical plant inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 04/15/2023. The LPA observed required postings in the hallway by the main entrance door.

KITCHEN: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

BEDROOMS: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition.

BATHROOMS: Bathrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

Continues on LIC809 C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BE WELL SENIOR LIVING INC.	FACILITY NUMBER: 197607890
	VISIT DATE: 03/12/2024

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OUTDOOR/GARAGE: Backyard has an area equipped with outdoor furniture for residents’ use. Shade is provided with patio umbrellas. No bodies of water noted. Side gate is unlocked. The property has a detached garage; the garage door was locked at the time of the visit. The washer and dryer are located behind the garage in an open space. Laundry and cleaning products are kept locked in the garage.

RECORDS: Records review began at 11:06 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:11 p.m.; medications are centrally stored and locked in a closet adjacent to the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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