198320009-5-2-2026-11-AS-ZBRN-DTPV3F-20260502160440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320009
Report Date: 05/02/2026
Date Signed: 05/02/2026 04:04:52 PM

Document Has Been Signed on 05/02/2026 04:04 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:	WELLNESS WORLD LLC		FACILITY NUMBER:	198320009
ADMINISTRATOR/ DIRECTOR:	GOMEZ, ELIZABETH C		FACILITY TYPE:	740
ADDRESS:	1119 E 215TH PL		TELEPHONE:	(213) 568-7298
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6		CENSUS: 5	DATE:	05/02/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Elizabeth Gomez (Adminstrator)		TIME VISIT/ INSPECTION COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/02/2025 at 12:45pm, the Department conducted an unannounced annual required visit using the CARE Inspection Tool. The Department met with staff member Elizabeth Gomez (Adminstrator) and purpose of the visit was explained. The facility is licensed to serve residents age 60 and over, of which six (6) may be non-ambulatory, one (1) may be bedridden, and the facility has a hospice waiver for three (3). The facility currently has five (5) residents in care with (1) on hospice & (3) on receiving home health. The facility’s annual fees are current. The facility administrator’s certificate is Elizabeth Gomez #7017473740 valid 10/25/2024 - 10/24/2026. The facility has liability insurance with Certain Underwriters at Lloyd's (policy #ISCAH0100000189-00) with each occurrence at $1,000,000 and general aggregate at $3,000,000 valid from 11/02/2025 - 11/02/2026 The facility is a two-story residential home located in a residential neighborhood. The licensed facility space is located on the first floor and consists of three resident bedrooms, two bathrooms, a living room, dining room, kitchen, laundry area, activity room, garage/storage area with 2 refrigerator, and a backyard with a shaded area. On 05/02/2026, between the hours of 12:47pm - 1:00pm, the Department toured the physical plant and observed no bodies of water or firearms/ammunition on the premises. All resident rooms were checked and found to have beds and bedding in good condition, adequate lighting, and sufficient storage space for personal belongings. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly, the shower was free of mold and mildew, lighting was adequate, and sufficient toiletries were accessible to residents. The water temperature properly measured between 105°F -120°F with temperature testing at 117.1°F in kitchen and 105.8 in Bathroom 1. Report continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WELLNESS WORLD LLC	FACILITY NUMBER: 198320009
	VISIT DATE: 05/02/2026

NARRATIVE

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The Department observed the facility to be clean, orderly, and appropriately furnished. Storage areas for personal hygiene items, cleaning agents, toxins, and sharps were locked and inaccessible to residents. The kitchen was inspected and found to have an adequate supply of perishable and non-perishable food stored properly. Medications were centrally stored and properly locked. The First Aid kit was fully stocked. Fire extinguishers were fully charged and inspected on 11/01/2025. Smoke and carbon monoxide detectors were operable. The facility also has a landline phone avaliable for the resident s

On 05/02/2026, between the hours of 1:05pm -2:35pm, the Department conducted a review of five (5) resident records, five (5) staff records, and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of the visit. The Department reviewed five (5) resident Medication Administration Records.

During today’s visit, the Department did observe the deficiencies during the annual inspections.
Based on observation, interview and records review, the facility did not have the following on file
Resident 1 (R1) - TB Test & No LIC 601 & LIC 625
Resident 2 (R2) - No LIC 601, LIC 602, LIC 603, LIC 625, No Hospice Care Plan
Resident 3 (R3) - No LIC 602, LIC 613, LIC 625
Resident 4 (R4) - No LIC 625
Resident 5 (R5) - No LIC 603, LIC 625 and No TB Test

An exit interview was conducted, and a copy of this Facility Evaluation Report was provided with Appeal Rights to the Administrator Elizabeth Gomez

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/02/2026 04:04 PM - It Cannot Be Edited

Created By: Zina Brown On 05/02/2026 at 03:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WELLNESS WORLD LLC	FACILITY NUMBER: 198320009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(b)

Personal Rights of Residents

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above for 1 out of 5 resident R3 had no LIC 613 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2026
	Plan of Correction
1 2 3 4	The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & records review, the licensee did not comply with the section cited above for 5 out of 5 residents did not have the following records on R1: TB Test & LIC 601/ 625, R2: LIC 601/602/603/625, R3: LIC602/613/ 625, R4: LIC 625 & R5: LIC 603/ 625 & TB Test which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/16/2026
	Plan of Correction
1 2 3 4	The facility will submit the proof of correction for all residents such as 1: TB Test & LIC 601/ 625, R2: LIC 601/602/603/625, R3: LIC 602/613/ 625, R4: LIC 625 & R5: LIC 603/ 625 & TB Test to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the 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.

	Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:

	Zina Brown
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/02/2026 04:04 PM - It Cannot Be Edited

Created By: Zina Brown On 05/02/2026 at 03:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WELLNESS WORLD LLC	FACILITY NUMBER: 198320009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not conducting nor having documentation on file for when the last quarterly emergency drill was conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2026
	Plan of Correction
1 2 3 4	The facility will conduct a quarterly emergency drill by the POC due date and submit proof to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov

Type B

Section Cited

CCR

87633(a)(4)

A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above for 1 out 5 residents by not having a hospice care plan on file for Resident 2 (R2) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2026
	Plan of Correction
1 2 3 4	The facility will obtain Resident 2 (R2) Hospice Care Plan from the company that is providing services to R2 by the POC due date and submit proof to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:

	Zina Brown
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2026

LIC809 (FAS) - (06/04)

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