197609307-9-20-2023-29-AS-CYEE-CVV335-20230920175258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609307
Report Date: 09/20/2023
Date Signed: 09/20/2023 05:53:13 PM

Document Has Been Signed on 09/20/2023 05:53 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:	09/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Vahe Mkrtchian, Administrator		TIME COMPLETED:	06:00 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 Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Karine Simonyan, Staff. Vahe Mkrtchian was contacted by staff and he arrived a little later to conduct the visit. Also present during this visit was Lala Karapetyan, Staff. The reason for today's visit was provided. The facility is a single storey 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. The following were observed on today's visit: The living room, dining room, kitchen have the appropriate furnishings and equipment. The only fire extinguisher purchased on 6/27/23 is located in the kitchen The four resident bedrooms contained a bed, a chair, a night stand, a lamp, a dresser and a closet. The beds were observed with a mattress cover, a fitted sheet and a blanket or a comforter. Per the Administrator, it is hot and the residents do not want to use a comforter and they were observed stored in the closet. A couple of fitted sheets and 1 flat sheet each were observed in the residents' dressers. The blinds in bedroom #3 was observed to be loose and could not be shut completely. Medications are centrally stored in a locked closet by the staff bedroom The 3 full bathrooms were toured. Bedroom #4 has a full bathroom installed with a shower, a toilet, a sink. Grab bars, shower chair and non-skid mat was observed. The water was tested and read 116.2 degrees Fahrenheit. The 2 common bathrooms are located in the hallway by the resident bedrooms. The common bathroom located by bedroom #3 is designated for staff use. It has a shower, toilet and a

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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: 09/20/2023

NARRATIVE

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sink. The common bathroom located directly in front of kitchen is equipped with a shower, a toilet and a sink. Grab bars and non-skid mats and shower chair were observed. Water temperature tested read 118.2 degrees Fahrenheit.
Food supplies were reviewed. Observed in the refrigerator were a couple of plastic containers with watermelon, 3 green bell peppers, 1 red bell pepper and two full 32 oz cartons of milk and a 1/3 quart of bottle of milk. Located in the pantry were 3 bananas and 4 apples. Snacks and breakfast foods were not observed Insufficient non-perishables were observed in the kitchen and consisted of small cans of soups and vegetables were observed. No pastas, sauces or rice were observed to make a balanced meal for 7 days. Snacks were low. Per Administrator, they are going marketing on Thursday..
Cleaning supplies are stored in a locked cabinet under the kitchen sink
The first aid kit was reviewed and contained gauzes, tapes, tweezer and scissors. The facility has a common thermometer. No first aid manual was observed.
The hardwired combination smoke/carbon monoxide detectors were tested and were operational.
The washer and dryer located outside the kitchen was observed in use and was operational
Per tour of the backyard, a gazebo with a table and 6 chairs were observed. Trash cans were tightly sealed.
The front yard was observed to be clean.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above per review of food in the pantry and refrigerator that there were insufficient perishable and non-perishables foods. There were 3 green and 1 red bell peppers, 2 plastic containers of water melon, 2-1/3 quarters of milk, yogurt in the refrigerator, 3 bananas and 3 apples in the pantry. Small cans of vegetables and soups were in the pantry, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	The Licensee will purchase the required perishable and non-perishable foods and fax over a copy of the receipt to licensing by 9/21/23

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2023 05:53 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLBE HOME	FACILITY NUMBER: 197609307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)(1-4)

87465 Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication. (2) The exact dosage.(3) The minimum number of hours between doses.(4)The maximum number of doses allowed in each 24-hour period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as no physicians orders were observed in any of the residents' files] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	The Licensee will contact the prescribing physicians to obtain copies of the physicians orders and maintain in the residents files. The Licensee will self ceritify that the physicians orders have been obtainied by 9/2/23

Type B

Section Cited

CCR

87465(a)(8)(a)

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above since a copy of the first aid manual was requested from the Administrator and was advised that the facility did not have one.] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	The Licensee will purchase a copy of the first aid manual that meets Title 22 requirements and provide evidence that it was purchased and will be maintainied at the facility.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2023 05:53 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLBE HOME	FACILITY NUMBER: 197609307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above per tour of bedroom #3, the blinds on the door leading outside were observed either missing a slate or broken as it did not close correctly to allow the resident in care privacy in the bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	The Licensee will ensure that residents are provided with well maintained window dressing to allow all residents priviacy in their rooms. Licensee will repair or replace the blinds on the side door of bedroom #3 and any other bedroom to allow resident privacy. Licensee will fax over evidence that the deficiency has been corrected by 9/27/23

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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