197608382-3-4-2022-29-AS-SURA-CC7LJS-20220304074827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608382
Report Date: 03/02/2022
Date Signed: 03/04/2022 07:49:20 AM

Document Has Been Signed on 03/04/2022 07:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	BE WELL SENIOR LIVING II INC.		FACILITY NUMBER:	197608382
ADMINISTRATOR:	ELINA ROOT		FACILITY TYPE:	740
ADDRESS:	5104 VARNA AVENUE		TELEPHONE:	(818) 646-3412
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY:	6	CENSUS: 6	DATE:	03/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Elina Root		TIME COMPLETED:	01:35 PM

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On 03/02/2022, at 11:20 a.m., Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena met with administrator Elina Root, and explained the reason for the visit.

Infection Control: At 11:25 a. m., upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed 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.

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

Common Areas: At 11:35 a.m., LPA Urena observed the walls and flooring to be clean and in good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition.

Kitchen: At 11:45 a.m., LPA Urena observed the kitchen/dining area. 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

Continues on LIC809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BE WELL SENIOR LIVING II INC.	FACILITY NUMBER: 197608382
	VISIT DATE: 03/02/2022

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Bedrooms: At 11:50 a.m., LPA Urena observed the residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. Each resident’s bedroom closet had its own supply of incontinent supplies, and clean linens.

Bathrooms: 12:00 p.m., LPA Urena observed the residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars and a non-skid surface. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: 12:15 p.m., LPA Urena observed the Outdoor space. Backyard is equipped with outdoor furniture for residents’ use. A shade umbrella is visible to provide shade in the outdoor area. There were no bodies of water noted. Side gate is unlocked.

No deficiencies cited during this visit. Exit interview was conducted. The report was reviewed with administrator Elina Root, and a copy of the report was provided. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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