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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608603
Report Date: 05/16/2022
Date Signed: 05/16/2022 01:07:47 PM


Document Has Been Signed on 05/16/2022 01:07 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
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: 5DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Francis Martir and Lourna MontemayorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 11:40 a.m. The LPA met with staff and explained the reason for the visit. The LPA spoke to Administrator Francis Martir over the phone, whom was unable to be present during today’s visit.

The LPA, along with staff, 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.

KITCHEN: Knives are stored inaccessible to the residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed the resident and staff bedrooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. RESTROOMS: The restrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed appropriate hand-washing signs in the restrooms. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. The washer and dryer are next to the kitchen. Cleaning supplies are kept locked and inaccessible. Passageways were clean and clear of obstructions. No bodies of water were noted in the backyard. The LPA encouraged staff to post signs to promote cough etiquette and signs and symptoms of COVID-19.

INFECTION CONTROL: The LPA and Administrator discussed the facility infection control practices and procedures. There is a central entry point for symptom screening, temperature checks, and hand hygiene. The LPA observed a supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. The facility can designate a single isolation room if the facility has a confirmed case of COVID-19. The Administrator is up to date regarding policies around vaccinations, visitation, and the testing protocol. The Administrator confirmed that they share all updates with residents, staff, and families. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited at this time. Exit interview conducted. Staff were authorized to sign the report.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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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