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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608603
Report Date: 05/04/2022
Date Signed: 05/05/2022 08:56:59 AM


Document Has Been Signed on 05/05/2022 08:56 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:LIVEWELL RESIDENTIAL CARE HOMEFACILITY NUMBER:
197608603
ADMINISTRATOR:FRANCIS MARTIRFACILITY TYPE:
740
ADDRESS:14315 VALERIO STREETTELEPHONE:
(818) 989-1073
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:02 PM
MET WITH:Lorna Montemayor, Staff TIME COMPLETED:
06:00 PM
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An unannounced Case Management - Incident visit was conducted to the above facility today. Reason for todays visit is to follow up on a reported death. Upon arrival Licensing Program Analyst (LPA) was greeted by staff. Staff contacted the Administrator. LPA spoke with Francis Martir at approximately 5:10pm. Reason for the visit was explained. Ms. Martir could not met LPA at the facility during todays visit and asked that staff assist LPA with the visit.

The purpose of the visit is regarding death of Resident #1 (R1), deceased at Valley Presbyterian Hospital today on 05/4/2020. Administrator called and reported that R1 was transported to the hospital today upon staff finding R1 on the floor in the restroom unresponsive.

During today's visit, LPA conducted a tour of the facility at 5:15pm with staff. LPA could not review residents file as Administrator took the file to fax requested documents to the Department. A brief interview was conducted with staff and Administrator. Administrator was informed prior to issuing final licensing report further investigation is needed at this time. Case was referred to Community Care Licensing Investigation's Branch (IB).

Exit Interview conducted and copy of today's report sent to Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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