197608382-2-21-2025-29-AS-EMOY-DE4VM5-20250221153259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608382
Report Date: 02/21/2025
Date Signed: 02/21/2025 04:51:48 PM

Document Has Been Signed on 02/21/2025 04:51 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 II INC.		FACILITY NUMBER:	197608382
ADMINISTRATOR/ DIRECTOR:	ELINA ROOT		FACILITY TYPE:	740
ADDRESS:	5104 VARNA AVENUE		TELEPHONE:	(818) 646-3412
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Elina Root Co- Administrator Ruslan Melnikov Co- Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

NARRATIVE

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff and called the Administrator to inform them of the visit. The Administrator arrived shortly after. The LPA met with Co- Administrators Elina Root and Ruslan Melnikov and explained the reason for the visit. The LPA toured the physical plant areas 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, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. At 1:10 p.m., smoke detector(s) and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 2/21/2025. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 12/1/2024 and conducted quarterly. Activities were observed in the common areas. An adequate supply of emergency water was observed in dining room area. An adequate amount of extra bedding and towels were observed in a hallway closet for resident use. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction.

KITCHEN: The LPA inspected the kitchen/food service area at 10:20 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 115.1 degrees Fahrenheit at 10:21 a.m. Cleaning solutions, toxins, chemicals, and hazardous items were inaccessible and locked away inside a kitchen cabinet under the sink.

Report Continued on LIC 809C...

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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 II INC.	FACILITY NUMBER: 197608382
	VISIT DATE: 02/21/2025

NARRATIVE

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Report Continued from LIC 809...
BEDROOMS: The facility is a single-story residential home with six (6) bedrooms that are for resident use. Resident bedrooms are private, single occupancy. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Inside temperature was maintained at a comfortable level. The laundry units, and cleaning solutions, are kept in the locked laundry room / staff bathroom.

BATHROOMS: The facility has a total of three (3) bathrooms. Two (2) are resident bathrooms of which one (1) is a shared resident use, one (1) is a private resident use, and one (1) for staff use. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. Hot water was measured in resident bathrooms. The shared bathroom measured at 132.1-degree Fahrenheit at 10:46 a.m. and the private bathroom at 135.1-degree Fahrenheit at 10:39 a.m. both over the required temperature of 105–120-degree Fahrenheit posing an immediate health and safety risk to persons in care. At the time of the visit the Administrator was able to adjust the water temperature and get it to the required range of 105–120-degree Fahrenheit with a temperature of 115.1 at 2:35pm. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE/ GARAGE: The LPA observed the back yard which had a shaded patio area with patio furniture including a table and chairs for resident use. The LPA observed one gate that self-latches with a clear passageway in case of an emergency. There were no bodies of water observed on the premises at the time of the visit. The garage is kept locked and inaccessible to residents. LPA observed an adequate amount of emergency food stored in the garage. LPA observed an extra refrigerator with extra food that was checked for proper labels and expiration dates.

RECORDS: Records review began at 10:57 a.m., six (6) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Record review revealed that Resident #2 (R2) was missing their TB results and Resident #4 (R4) and Resident #6 (R6) were missing an updated needs and services plan posing a potential health and safety risk to persons in care. At 12:00 p.m. four (4) Personnel records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Report Continued from LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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 II INC.	FACILITY NUMBER: 197608382
	VISIT DATE: 02/21/2025

NARRATIVE

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Report Continued from LIC 809C...

INTERVIEWS: One (1) staff and two (2) resident interviews were conducted during the inspection. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

MEDICATIONS: Medications review began at approximately 12:51 p.m. Medications are centrally stored and locked in a kitchen cabinet; medications are labeled and were checked for expiration dates. During the medication review the LPA and Administrators observed that the medications were prepped two (2) days in advance for all six (6) residents which poses a potential health and safety risk to persons in care.

Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, and current Liability Insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2025 04:51 PM - It Cannot Be Edited

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 II INC.	FACILITY NUMBER: 197608382
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two (2) out of two (2) bathrooms had water temperature above 120 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	At the time of the visit the Administrator was able to adjust the water temperature and get it to the required range of 105–120- degree Fahrenheit with a temperature of 115.1 at 2:35pm. Licensee agrees to keep a water log for the bathrooms of the home. Begin the water log today 02/21/25 through 02/28/25 and send a copy of the completed water log to LPA by 03/05/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2025 04:51 PM - It Cannot Be Edited

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 II INC.	FACILITY NUMBER: 197608382
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and medication audit, the licensee did not comply with the section cited above in six (6) out of six (6) medications were prepped two (2) days in advance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	Licensee will submit a statement of understanding confirming they have reviewed CCR 87465 and will submit a statement that they will not prep medications more than one day in advance. Licensee will submit the required documents to CCL no later than POC due date.

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two (2) out of six (6) resident needs and services plan were not properly updated which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	Licensee will conduct an audit on resident files enuring they are all accurately updated. Licensee will submit a statement of understanding confirming they have reviewed CCR 87506.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2025 04:51 PM - It Cannot Be Edited

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 II INC.	FACILITY NUMBER: 197608382
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one (1) resident Resident #2 (R2) was missing their TB test / results which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	Licensee will have R2 get their TB test and send proof to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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