197608603-12-31-2021-29-AS-SWAR-CA8Q5G-20211231105156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608603
Report Date: 12/31/2021
Date Signed: 12/31/2021 10:52:50 AM

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:	FRANCIS MARTIR		FACILITY TYPE:	740
ADDRESS:	14315 VALERIO STREET		TELEPHONE:	(818) 989-1073
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 6	DATE:	12/31/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Erlana Tolentino		TIME COMPLETED:	10:55 AM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management-Incident visit today to follow up on an incident report received by the Woodland Hills North Regional Office on December 14, 2021. During today’s visit, LPA Walker met with Erlana Tolentino at 9:20 a.m., and explained the reason for the visit. Upon arrival, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards at 9:25 a.m.

On 12/14/2021, the facility self- reported an incident which noted Resident #1 (R1) eloped from the facility the evening of 12/10/21; and had yet to return to the facility as of reported date 12/14/21. The incident report also noted R1 ‘is independent and is able to spend time outside of the facility.’

On 12/16/2021, LPA Ashley Smith contacted administrator Francis Martir whom stated that R1 did not have a history of eloping. The administrator stated to the LPA that R1’s case manager was contacted, and a police report was filed. The LPA emailed the administrator requesting documents from R1’s file.

On 12/21/2021, LPA Salia Walker contacted administrator Francis Martir to follow up on the status of R1’s elopement. The administrator stated R1 had not returned to the facility as of this date, and the facility nor Case Manager had any updates.

Continue on LIC809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

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: 12/31/2021

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On 12/23/2021, LPA Walker contacted administrator Francis Martir to obtain additional information after reviewing the documents submitted by the administrator from R1’s file. The administrator confirmed there were two (2) staff on shift during the time R1 eloped from the facility, and that there are two (2) staff per shift. The administrator also stated R1 would ‘go out every three (3) days.’ The administrator informed the LPA that R1 would leave in the afternoons, and come back before sundown. The administrator stated staff notified that R1 would usually go to the corner store or some sort of convenient store to get cigarettes. LPA Walker advised the administrator that R1’s Physicians Report states R1 is not able to leave the facility unassisted. The administrator alleged that upon R1’s admission to the facility, R1’s previous case manager informed them that R1 likes to leave for a couple of hours, and this was the reason the facility allowed R1 to continue to come and go from the facility unassisted. The administrator stated the last time R1’s case manager was contacted was on Monday 12/20/21. The administrator also clarified that the facility did not file a missing person report with law enforcement, but that a police report was filed for R1 allegedly assaulting another resident in the facility. The LPA advised the administrator that an administrator of the facility, or designee, shall notify local law enforcement when a resident is missing from the facility. The LPA attempted to contact R1’s case manager on 12/23/21, 12/28/21, and 12/30/21.

During today’s visit, the administrator confirmed via telephone the facility did not follow up and formally notify local law enforcement that R1 eloped from the facility and is currently still missing, resulting in an informal police report.

Based on record review and interview with the administrator, there is sufficient evidence to confirm that R1 eloped from the facility, as the facility did not abide by R1’s physicians report allowing R1 to leave the facility unassisted. Additionally, the facility did not follow their “Program Plan - Absentee Notification Plan (AWOL): 2. The administrator or administrator designee or facility authorized representative will contact by telephone local law enforcement and report a missing person,” as they failed to formally notify local law enforcement when R1 became missing from the facility.

Pursuant to Title 22 of the California Code of Regulations, and the California Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's report and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

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: 12/31/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/05/2022 Section Cited	1 2 3 4 5 6 7	87464(f)(1) Basic Services (f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interview and records review, the licensee did not comply with the section cited above, as the facility failed to ensure that R1 did not leave the facility unassisted per the physician report, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 01/03/2022 Section Cited	1 2 3 4 5 6 7	§1569.317 Absentee notification plan for missing residents: Every residential care facility for the elderly.. shall notify local law enforcement when a resident is missing from the facility. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on Interview with the administrator, the licensee did not comply with the section cited above, as the facility failed to formally notify local law enforcement when R1 became missing from the facility, which poses an immediate health, and safety risk to persons in care.	8 9 10 11 12 13 14

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: 12/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

LIC809 (FAS) - (06/04)

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