197608603-6-14-2021-29-AS-SWAR-C3YU9S-20210614152338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608603
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:26:30 PM

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:	LIVEWELL RESIDENTIAL CARE HOME		FACILITY NUMBER:	197608603
ADMINISTRATOR:	FLORY M. MORALES		FACILITY TYPE:	740
ADDRESS:	14315 VALERIO STREET		TELEPHONE:	(818) 989-1073
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 4	DATE:	06/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Neil Morales, Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Salia Walker and Ashley Morgan arrived at the facility unannounced to conduct a required annual visit at 12:45PM. This annual had a specific emphasis on infection control practices and procedures. Administrator Neil Morales arrived at approximately 1:25 PM and the LPAs explained the reason for the visit.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: Knives are stored and locked in the kitchen cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 01:29PM, the LPAs observed expired condiments, and milk. Pest were also observed in the refrigerator. At 01:31PM, the LPAs observed expired canned goods in the pantry.

LAUNDRY AREA: At 01:27PM Laundry area was observed to be located next to kitchen. Laundry detergent was locked and inaccessible.

BEDROOMS: The LPAs observed the resident and staff bedrooms which were furnished with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs. LPAs also advised administrator to ensure restrooms have appropriate lighting.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the hallway.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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: LIVEWELL RESIDENTIAL CARE HOME	FACILITY NUMBER: 197608603
	VISIT DATE: 06/14/2021

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The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage contains additional perishable food items. The garage is detached to the facility.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPAs observed a supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient, and facility has sufficient disinfectants. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

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. 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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: LIVEWELL RESIDENTIAL CARE HOME	FACILITY NUMBER: 197608603
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 as expired food was observed, which poses a potential health, and safety risk to persons in care.
	POC Due Date: 06/16/2021
	Plan of Correction
1 2 3 4	Administrator agreed to do the following: Audit all food, and submit proof of completion by 06/16/21.

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 as there were insects in the refridgerator which poses a potential health, and safety risk to persons in care.
	POC Due Date: 06/16/2021
	Plan of Correction
1 2 3 4	Administrator agreed to do the following: Clean all refridgerators and pantries. Submit statement of completion by 06/16/21.

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

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