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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609336
Report Date: 09/21/2024
Date Signed: 09/21/2024 05:15:58 PM


Document Has Been Signed on 09/21/2024 05:15 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 45DATE:
09/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Maria Cox & Maria Schwartz TIME COMPLETED:
03:05 PM
NARRATIVE
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On 09/21/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Activities Director Maria Cox and Business Office Director Maria Schwartz. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (50) non-ambulatory elderly adults. The facility is approved for (15) hospice residents.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (50) resident bedrooms, (50) resident bathrooms and (4) public restrooms, a dining room, a laundry room, business offices, an industrial kitchen, outdoor patio, a salon, a med room, and an employee lounge.

LPA Dabuet and Schwartz toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #110, #102, #115, #113, #202, and #221. Bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. A comfortable temperature was maintained in the facility at 73 - 79 degrees F.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately.

Evaluation Report continues LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024
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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Document Has Been Signed on 09/21/2024 05:15 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified staff #6 not have criminal record clearance transfer. Staff did not have an LIC 9162 on file nor transfered on CDSS Guardian. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2024
Plan of Correction
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Licensee will ensure all staff have criminal clerance transfer prior to working at the facilty. Staff #6 according to CDSS Guardian is not associated to this facility. Licensee will associate staff #6 by POC due date. Send proof of correction by email to ernand.dabuet@dss.ca.gov
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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2024 05:16 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(5)
87705 Care of Persons with Dementia - (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified resident #2 & #4 both diagnosed with dementia did not have current medical assessment & reappraisal. Last assessments were done in 2022. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2024
Plan of Correction
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Licensee will ensure that all residents diagnosed with dementia will have medical and reappraisal done annually. Proof of correction for resident #2 & #4 of current medical assessment & reappraisal be completed and submitted by email before due date to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Staff #3 #4 #5 did not have First Aid/CPR certificate on file. This violation which poses a potential health, safety, or personal rights risk to persons in care
POC Due Date: 10/12/2024
Plan of Correction
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Licensee/Administrator will ensure all facility staff must have the mandatory First Aid/CPR Training completed. As plan of correction, administrator will send proof of completed First Aid/CPR will be sent to LPA via email: ernand.dabuet@dss.ca.gov before POC due date.
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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/21/2024 05:16 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)(11)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Staff #3 did not have a health screening nor TB test results on file. This violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2024
Plan of Correction
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Licensee/Administrator will ensure all facility staff have completed a Health Screening LIC 503 and TB test results. As plan of correction, administrator will send proof of Health Screening LIC503 with TB test results to LPA via email: ernand.dabuet@dss.ca.gov before POC due date.
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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELBROOK SENIOR LIVING SANTA MONICA
FACILITY NUMBER: 197609336
VISIT DATE: 09/21/2024
NARRATIVE
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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

LPA conducted an audit of resident #1-#5 (R1-R5) service files, and staff #1-#5 (S1-S5) personnel files were in order. The facility is current in CCLD annual fees. The administrator certificate for Cole Catalina 7022822740 is in pending renewal status. The facility has a Liability Insurance Certificate valid 11/24/23 through 11/24/24. The facility is current on CCLD annual license fees.

DEFICIENCIES:
Audit of staff roster and schedule revealed Staff #6 did not have Criminal Clearance Transfer Associated to this facility. Records indicated no LIC 9162 or appears on CDSS Guardian System. Staff #3, #4, and #5 all did not have current First Aid/CPR certificate on file. Staff #3 did not have a LIC 503 Health Screening on file Staff #3 did not have TB test results. Resident #2 and #4 diagnosed with Dementia did not have current medical assessment and reappraisal on file.

Advisory - Technical Violation (see LIC 9102)

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).

An exit interview conducted with the Maria Schwartz, and a copy of the report is provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024
LIC809 (FAS) - (06/04)
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