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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609307
Report Date: 08/10/2021
Date Signed: 08/10/2021 06:10:11 PM

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:WELLBE HOMEFACILITY NUMBER:
197609307
ADMINISTRATOR:MKRTCHIAN, VAHEFACILITY TYPE:
740
ADDRESS:12936 WELBY WAYTELEPHONE:
(818) 414-0005
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
08/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Vahe Mkrtchian, AdministratorTIME COMPLETED:
04:11 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a Required Annual visit at 09:12 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Vahe Mkrtchian at 09:27 a.m., and explained the reason for the visit.

When LPA Walker was knocking at the front door at 09:12 a.m., the LPA heard knocking coming from inside the facility. Upon entry at 09:21 a.m., LPA Walker met with the only staff present in the facility, caregiver #1. Upon review of the facility personnel report summary, the LPA observed that caregiver #1 is not associated with the above facility. The LPA then focused on the knocking sounds coming from room #2. The LPA advised caregiver that the knocking appeared to have been continuing since 09:12 a.m. The LPA asked the caregiver to ensure that the resident was not in any distress. Resident #1 (R1), who was exiting their room at the time, stated that resident in room #2 always knocks on the door and that the knocking never ends.
At 09:23 a.m., the LPA observed that Room #2 appeared to be locked. Caregiver #1 stepped away to retrieve a key, which was utilized to turn the lock on the doorknob and unlock the door to room #2. Resident #2 (R2) stepped out of room #2 and sat on the couch. The LPA asked why room #2 door was locked. Caregiver #1 stated that R2 always tries to get out. Caregiver #1 also stated that R2 tries to get away gesturing with hand he tries to exit the facility. The LPA checked the doorknob and confirmed that the door was locked from outside room #2, and that R2 had no way to exit. The LPA also observed room #2 had an emergency exit door which was also locked and inaccessible. At 09:25 a.m., caregiver #2 arrived at the facility. At 09:25 a.m., the LPA also received a telephone call from the administrator to inform the LPA of the anticipated time of arrival. The LPA advised the administrator of room #2 being locked. The administrator stated that R2 locks the door from the inside. The LPA advised the administrator that the LPA checked the door from inside and confirmed there was no way to lock the doorknob from inside the room as the lock piece had been removed. (Photos were taken by the LPA). The LPA advised the administrator of the statements caregiver #1 made.
Continue on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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 5
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: WELLBE HOME
FACILITY NUMBER: 197609307
VISIT DATE: 08/10/2021
NARRATIVE
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At 09:27 a.m., the administrator arrived at the facility. The LPA advised the administrator the locked door was a Personal Rights Violation, as well as a Fire Safety/Clearance Violation. The LPA advised the administrator of the immediate Health and Safety risk the locked door poses to any resident, but especially to R2, due to a diagnosis of Epilepsy. The administrator stated the facility ordered a new doorknob, and that the reason for the current doorknob was due to R2 breaking other doorknobs.

The LPA toured the physical plant areas inside and outside to ensure there are no other health and safety hazards at 09:52 a.m.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Restroom one (1) hot water measured 113.6 Fahrenheit at 09:56 a.m. Restroom two (2) hot water measured 116.4 Fahrenheit at 10:06 a.m. Restroom three (3) hot water measured 117.3 Fahrenheit at 10:07 a.m.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 114.1 Fahrenheit at 10:12 a.m.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the kitchen, with the exception of CDSS PINs which the LPA advised the administrator must be printed and displayed for staff and residents. One fire extinguisher was observed to be fully charged and purchased on 07/28/2021.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The Laundry area is located in the backyard. The garage is detached to the facility. The garage contains additional nonperishable and perishable food items. At 10:16 a.m., the LPA observed insufficient amount of emergency water for facility. Administrator stated facility will purchase sufficient emergency water.

Continue on LIC 809C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: WELLBE HOME
FACILITY NUMBER: 197609307
VISIT DATE: 08/10/2021
NARRATIVE
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.


The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Civil Penalties were issued (See LIC 421).

Exit interview conducted. A copy of the report and appeal rights were provided via email..

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: WELLBE HOME
FACILITY NUMBER: 197609307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(6)


This requirement is not met as evidenced by:

Based on observation, the Licensee did not comply with the section cited above. As the Licensee failed to ensure to not have residents locked into any rooms, which poses a potential health and safety risk to resident in care.
Deficient Practice Statement
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87468.1(a)(6) Personal Rights of Residents in All Facilities: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.
POC Due Date: 08/10/2021
Plan of Correction
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Administrator replaced the doorknob on resident's room, with no lock. POC was clear at the time of visit on 8/10/2021.
Type A
Section Cited
CCR
87202


This requirement is not met as evidenced by:

Based on observation, the Licensee did not comply with the section cited above. As the Licensee failed to maintain the facility in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic, which poses a potential health and safety risk to resident in care.
Deficient Practice Statement
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87202 Facility Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
POC Due Date: 08/10/2021
Plan of Correction
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Administrator replaced the doorknob on resident's room, with no lock. POC was clear at the time of visit on 8/10/2021.
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: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: WELLBE HOME
FACILITY NUMBER: 197609307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)


This requirement is not met as evidenced by:
87411(a) Personnel requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
Deficient Practice Statement
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Based on documents reviewed, the licensee did not comply with the section cited above. As the licensee failed to ensure there was an adequate amount of staff, which poses a potential health and safety risk to residents in care.
POC Due Date: 08/13/2021
Plan of Correction
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Administrator agreed to submit proper documentation to LPA in order to associate staff with the facility by 8/13/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5