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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609336
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:05:35 PM


Document Has Been Signed on 10/04/2023 03:05 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:WELBROOK SENIOR LIVING SANTA MONICAFACILITY NUMBER:
197609336
ADMINISTRATOR:COLE, CATALINAFACILITY TYPE:
740
ADDRESS:1450 17TH STREETTELEPHONE:
(424) 282-3002
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:50CENSUS: 43DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David Cole - Vice President of Operations TIME COMPLETED:
03:30 PM
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On 10/4/2023, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection and met with David Cole, Administrator & Vice President of Operations.

Facility is licensed to serve 50 residents and 15 hospice with dementia waiver. The Annual Licensing Fees are current.

The facility consists of 2 floor levels, 50 resident bedrooms, 1 industrial kitchen, 1 dinning area, 1 outside patio, and common areas.

The administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 111.8 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Smoke detectors, carbon monoxide detectors, and fire extinguishers are tested annually. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 10/04/2023
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5 resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

An exit interview was conducted, A copy of this report and appeal rights were discussed and left with the administrator.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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