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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608603
Report Date: 06/17/2022
Date Signed: 06/17/2022 09:38:05 AM


Document Has Been Signed on 06/17/2022 09:38 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: 5DATE:
06/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lorna MontemayorTIME COMPLETED:
09:45 AM
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 inspection of complaint control # 29-AS-20220527104820. Upon entry, the LPA was met by staff.

On 06/02/22, during the physical plant tour with Administrator Francis Martir, the LPA observed that the facility’s “back house”/building located in the back yard was renovated and converted for Human habitation. The LPA inquired with the Administrator as to whether the Licensee or owner obtained an approved city permit for the conversion. The Administrator stated they believed the owner did obtain an approved city permit for the conversion. On 06/08/22, LPA Walker conducted a record review. Record review revealed that there is no approved city permit under the facility’s property address for the conversion of the “back house”/ building for human habitation. On 06/14/22, the LPA received an email from the administrator stating they spoke to the owner of the property about the permits and the owner stated they “will not get permits for the back house since it has no part in our facility.” The Administrator acknowledged they were under the impression the owner did have permits to make the modifications initially.

Based on LPAs observation, record review, and interviews conducted, the Licensee failed to obtain an approved city permit, and fire clearance for the conversion of the back house/building for Human Habitation. The Licensee also failed to maintain a current, written definitive plan of operation filed in the facility and submitted to the licensing agency with the significant changes in the plan of operation.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Civil penalties issued. Failure to correct the deficiencies may result in civil penalties being assessed.
Exit interview conducted. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/17/2022 09:38 AM - 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: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

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87202(a) Fire Clearance: (a)All facilities shall maintain.. licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the...city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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Based on record review and interviews conducted, the licensee did not comply with the section cited above as the Licensee did not obtain a fire clearance and city permit for the conversion of the back house/building, which poses an immediate health and safety risk to residents in care.
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Type B
06/24/2022
Section Cited

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87208(a) Plan of operation: Each facility shall have and maintain a current, written definitive plan of operation… Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval…
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above as the Licensee did not submit an updated plan of operation noting the facility’s back house/ building was converted for Human habitation, which poses a potential health and safety risk to residents 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: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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