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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610094
Report Date: 02/24/2022
Date Signed: 02/24/2022 10:54:16 AM


Document Has Been Signed on 02/24/2022 10:54 AM - 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:WELLNESS ASSISTED LIVINGFACILITY NUMBER:
197610094
ADMINISTRATOR:MELIKSETYAN, LUSINEFACILITY TYPE:
740
ADDRESS:9115 N WYSTONE AVETELEPHONE:
(747) 218-9141
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:MELIKSETYAN, LUSINETIME COMPLETED:
11:10 AM
NARRATIVE
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At 9:15 a.m., Licensing Program Analyst (LPA) Melissa Ruiz and conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff (S1) who granted access to the home and later met with Administrator Lucine Meliksetyan. This is a 4-bedroom, 3-bathroom single story residential care facility for the elderly. A physical tour was initiated at 9:30 a.m. and observed the following:

Infection control: Some signage was observed outside the home and along the main entrance of the facility. Upon entrance, staff took LPA's temperature but was not asked to sign-in the visitor’s log or was not asked any infection control questions. Hand sanitizer was available, and trash cans were observed to have closed tight fitting lids. Sufficient PPE supplies were observed.

Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored in and are kept locked. Smoke detectors/carbon monoxide were located throughout the facility. At 10:20 a.m., they were tested and are functional. Fire Extinguisher has a date of purchase of 10/13/2021. Resident rooms: All bedrooms are properly furnished, clean, and have appropriate bedding and linens. Bathrooms: The hot water temperature measured at 113.6 F. Extra towels and linens were readily available. Non-skid mats and appropriate grab bars were visible. Living Room: There is a large black leather sectional sofa that is showing extreme signs of wear and tear. All of the seat cushions are peeling. Garage there is an attached garage that leads to the outside. It is kept locked.

(cont. on 809-C)

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
VISIT DATE: 02/24/2022
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Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. Care and supervision: LPAs observed one staff to 6 residents on duty. One staff is tasked with providing care and supervision, which include by not be limited to changing residents, assisting residents with toileting needs, assistance with medications, transfers, etc. Staff are also tasked with screening visitors as they come into the facility. One staff is unable to meet all these needs and keep any eye on everyone.

Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D's included with this report. Report delivered. Appeal rights issued. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/24/2022 10:54 AM - 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2022
Section Cited

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above. One staff member was observed to take care of all 6 residents at once which poses a potential health, safety or personal rights risk to residents in care.
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Type B
03/03/2022
Section Cited

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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 evidence by:
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Based on observation, the licensee did not comply with the section cited above. The large black leather sectional seats were peeling and was observed to be in overall poor repair.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3