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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609336
Report Date: 10/13/2021
Date Signed: 10/13/2021 01:24:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:WELBROOK SENIOR LIVING SANTA MONICAFACILITY NUMBER:
197609336
ADMINISTRATOR:COLE, DAVIDFACILITY TYPE:
740
ADDRESS:1450 17TH STREETTELEPHONE:
(424) 282-3002
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:50CENSUS: 30DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:David ColeTIME COMPLETED:
01:35 PM
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On 10/13/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Executive Director David Cole and explained the purpose of today’s visit is to conduct the Infection Control annual inspection. The facility is licensed for (50) fifty Non-ambulatory residents. Facility has a hospice waiver for (15) fifteen. Currently, there are (30) thirty residents in care.

The facility is a two-story structure. The facility consists of the following: (50) fifty resident bedrooms with attached bathrooms, reception area, living room, 2 activity rooms, kitchen, dining room and outdoor covered patio.

LPA and Executive director toured the physical plant. There were no bodies of water or obstructions on the premises. Bathrooms were found to be within Title 22 regulations and fixtures are clean, in good repair, and working properly..

Storage area for cleaning supplies, toxins, and sharps objects was not accessible to clients. Smoke detectors were observed to be hardwired and interconnected. Facility has 14 fully charged fire extinguishers.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility. All mandated inspection control posters were posted and available.

No deficiencies were cited during this inspection visit.
Advisory notes were issued, and technical assistance was provided.

An exit interview was conducted, and a hard copy of this report was provided to Executive Director David Cole.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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