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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608603
Report Date: 06/02/2022
Date Signed: 06/02/2022 02:42:29 PM


Document Has Been Signed on 06/02/2022 02:42 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:
06/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Francis Martir, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management-Deficiencies inspection at the facility today due to deficiencies observed during the initial complaint visit of complaint control #29-AS-20220527104820.

At 11:47 a.m., the LPA observed the facility’s kitchen refrigerator containing one (1) ‘Trulicity’ injection pen, and one (1) bottle of ‘Pepto Bismolultra’; unsecured, and accessible to residents in care. The LPA advised the administrator medication shall be stored inaccessible to residents with dementia. During the visit, the Administrator stored and secured the two (2) medications in a lock box inaccessible to residents with dementia.



Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted, today's report and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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Document Has Been Signed on 06/02/2022 02:42 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
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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2022
Section Cited

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87705(f)(2) Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... and disinfectants.

This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above as the facility's kitchen refrigerator contained two (2) medications accessible to residents with dementia, which poses an immediate health, or safety risk to persons in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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