197609307-9-16-2024-29-AS-EMOY-D93U6J-20240913151824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609307
Report Date: 09/13/2024
Date Signed: 09/16/2024 03:30:48 PM

Document Has Been Signed on 09/16/2024 03:30 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WELLBE HOME		FACILITY NUMBER:	197609307
ADMINISTRATOR:	MKRTCHIAN, VAHE		FACILITY TYPE:	740
ADDRESS:	12936 WELBY WAY		TELEPHONE:	(818) 414-0005
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	4	CENSUS: 4	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	VAHE MKRTCHIAN		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:30 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with Administrator VAHE MKRTCHIAN and explained the reason for the visit. The LPA 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. The facility is a single-story home consisting on a living room, a kitchen, a dining room, 5 bedrooms, 3 full bathrooms and a detached garage located at the back of the property. Part of the garage has been converted to an office and part of the garage is used for storage. The facility is fire cleared for 5 non-ambulatory and 1 bedridden. However, at the request of the Licensee, the facility is licensed for a total of 4 residents of which 1 may be bedridden. Any of the resident bedrooms may be used for the bedridden resident. RESTROOMS: There are two (2) designated resident restrooms, one (1) of which is a private restroom and one (1) is a shared restroom. One (1) restroom is designated as a staff restroom which remains locked, however can be used in emergency situations. All three (3) restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured for all restrooms between 11:20 a.m. to 11:31 a.m.; the first restroom, designated as the shared restroom measured at 110.9 degrees Fahrenheit at 11:20 a.m., the second, private restroom measured at 114.6 degrees Fahrenheit at 11:31 a.m. the third staff restroom measured 114.6 at 11:26 a.m. all within the required range. Report Continued on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLBE HOME	FACILITY NUMBER: 197609307
	VISIT DATE: 09/13/2024

NARRATIVE

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Report Continued from LIC 809...
BEDROOMS: There are five (5) total bedrooms in the facility; One (1) is designated as a staff room which remains locked at all times, four (4) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

KITCHEN: The LPA inspected the kitchen/food service area at 11:32 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 116.8 degrees Fahrenheit at 11:33 a.m. all within the required range. Chemicals, cleaning supplies, and laundry detergent was observed in a locked cabinet under the sink inaccessible to residents.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 11:44 a.m., hard wired smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed, fully charged, and purchased on 05/14/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/24/2024 and are done quarterly. Activities were observed in the common areas.

GARAGE/BACKYARD: The garage is maintained locked at all times. There is a washer and dryer on premises. LPA observed an adequate amount of emergency food and water outside in a small shed. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water noted at the time of the visit.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLBE HOME	FACILITY NUMBER: 197609307
	VISIT DATE: 09/13/2024

NARRATIVE

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Report Continued from LIC 809C...

MEDICATIONS: Medications review began at approximately 1:00 p.m. The medications are locked in a closet adjacent to the staff room. Medications for four (4) out of four (4) residents were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. Facility uses the application ALCOMY that documents medication and is used by all staff.

RECORDS: The LPA and Administrator reviewed P&I money at 12:13 p.m. for one (1) resident. One (1) out of four (4) residents have facility manage cash resources. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash.

Resident Records were reviewed beginning at 11:48 a.m. and personnel records at 12:30 p.m. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Personnel files: Four (4) files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Three (3) staff interviews were conducted. There were no clients available for interview during the inspection.

Documents obtained include LIC 500, LIC 9020, COPY of SURETY BOND and COPY OF LIABILITY INSURANCE.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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