197609565-12-22-2022-31-AS-NRED-CMCUKV-20221222143946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609565
Report Date: 12/22/2022
Date Signed: 12/22/2022 02:39:58 PM

Document Has Been Signed on 12/22/2022 02:39 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WHOLESOME LIFE SENIOR LIVING		FACILITY NUMBER:	197609565
ADMINISTRATOR:	TASHCHYAN, ARPINE		FACILITY TYPE:	740
ADDRESS:	22040 COVELLO ST		TELEPHONE:	(310) 975-5452
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS: 5	DATE:	12/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Terrence Ferrer		TIME COMPLETED:	02:51 PM

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At approximately 1:30 p.m. on 12/22/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 12/02/2021 for an annual visit. It is a single story building with 7 bedrooms, 3 bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden. Approved hospice waivers for 3.

Upon entry, LPA observed signs posted at the main entrance for the facility’s visitation and masking policies. Once inside, LPA observed additional postings including the facility license, emergency disaster plan, Ombudsman contacts, confidential complaint contacts, personal rights, theft and loss policy, COVID precautions, and house rules.

The screening station contained a digital thermometer, visitor log, hand sanitizer, sanitizing wipes, surgical masks, and N95 masks. The facility had 7 private bedrooms. One bedroom served as a staff room. The staff room was free of hazards. Bedroom #1 was vacant. Bedroom #4 contained a bed with half rails and an unlocked exit with a ramp leading out. The ramp and its handrails were secure. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The facility had 3 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash cans, grab bars near the toilet and shower, and a non-skid mat in the shower. At 1:52 p.m. LPA measured the water temperature in Bathroom #1 to be 119.5 degrees. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 1:56 p.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Gingerbread houses made by residents were displayed on the dining room table. One resident was observed watching television in the living room.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WHOLESOME LIFE SENIOR LIVING	FACILITY NUMBER: 197609565
	VISIT DATE: 12/22/2022

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LPA observed an adequate supply of perishable and non-perishable food in the kitchen. The house telephone was located on the counter top. The stove hood was clean and surfaces were sanitary. Sharps were locked below the counter. A locked laundry area was located near the kitchen. It contained two functional appliances and inaccessible cleaning solutions.

All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches. At approximately 2:05 p.m. staff tested the dual-purpose smoke and carbon monoxide detector to be operational. At 2:07 p.m. LPA observed a fully charged fire extinguisher near the kitchen. Medications were locked near the staff room, and the kitchen contained a spare, locked refrigerator for chilled medications. Outside, LPA observed a grill and patio furniture in good condition.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC809 (FAS) - (06/04)

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